Medical Evaluation: Patient Assessment & Recording Styles

The patient must be Oriented to the environment be comfortable Oriented with the therapist & settings dressing and undressing examinati...

The patient must be Oriented to the environment be comfortable Oriented with the therapist & settings dressing and undressing examination table examination room presence of parents. Types of Assessment * Informal assessment:  It is a general overall view of the patient's performance.  It is done through observation in a non structural manner.  It is used just to locate the affected part. i.e. Quick test. * Formal assessment:  It is organized for a structural presentation. Individual tasks are used to elicit identifiable behavior, i.e. Functional test.  * Standardized assessment:  It is highly structural with strict procedures as; presentation, timing and scoring, i.e. Grade 3 muscle testing, EMG. Styles of clinical evaluation  There are two different styles for writing clinical evaluations and progress notes: * Narrative notes: It is a story telling generalized report. * Problem oriented medical recording (POMR): It is a system designed as a plan for assembling patient's data, organizing them by problem, thus, assuring a logical framework for delivery of health care.  Problem oriented medical recording  It is an orderly record, keeping system designed to record and communicate the process of patient's care.  It is superior to the narrative notes because it has a definite organized format. The format is abbreviated as SOAP.  S = Subjective.  O = Objective.  A = Assessment.  P = Planning.  Comparison between Narrative notes and POMR note: POMR Narrative note - It has a definite format with guidelines to - No definite format to guide document clinical findings. documentation of clinical findings. - Information is easily located within a familiar style. - Difficult to seek out information as a result of the story telling style. - The clinical findings are thorough, concise and orderly. Reading is easy and - There is tendency to write too much, time consuming and not easily read by information can be extracted in short period doctors, physical therapists and nurses. of time. - The clinical picture is easily established and - Poor planning for treatment of patient because the clinical picture is not the progress is quickly noted. So, the established and progress poorly treatment plan becomes obvious. reported. - The initial evaluation and progress note for - The narrative notes are useful in regularly seen patients should be written progress reports with no change in with SOAP format. patient's state. - A one visit consultation for patient evaluation - If the patient is seen only once for a and reporting of recommendation to a minor problem, a brief narrative note is physician should be carried out with SOAP appropriate. format. Advantages of POMR  Detailed reminder of clinical and laboratory information and therapy.  Source of information about the patient's past illness and treatment.  Easy communication with medical and paramedical staff members.  Can be used easily in evaluation, treatment plan and clinical research.