Initial Evaluation Documentation Outline & Tips PDF

Documentation Outlines and Tips: Initial Examination/Evaluation Sections of the Physical Therapy Initial Examination/Evaluation Note: Types of Data and Overlap with the SOAP Format...

Documentation Outlines and Tips: Initial Examination/Evaluation Sections of the Physical Therapy Initial Examination/Evaluation Note: Types of Data and Overlap with the SOAP Format History Demographics General information (name, date of birth (age), medical diagnosis, preferred language, etc.) (This information may be gathered from the patient, family member/caregiver, medical chart, intake form, or combination of sources) Current Condition Chief Concern: Main issue for which they are seeking care (Medial Diagnosis or Reported Impairments/Activity Symptom Behavior: (may be pain, other impairment, or Limitations/Participation Restrictions) functional limitation) Location/Description o Location(s), descriptive words, quality, etc (if indicated) Intensity o Often 0-10 scale (worst, best, current) Aggravating Factors o Things that increase severity or difficulty o How much required to increase to worst Easing Factors o Things that lessen severity or difficulty o How much required to decrease to best Frequency/Duration Examination o Episodic, intermittent, constant; timeframes if Subjective available 24-Hr Behavior o Time of day questioning (Morning, mid-day, afternoon, nighttime) Symptom History: Mechanism of Injury/Disease Onset o When condition started and how it developed? Timing & Pattern of Symptoms o Story of current condition from time of onset until they are seeing you Prior Episodes o Has it occurred before? Previous Examination/Intervention Sometimes the negative is o Who else have they seen (current referral source and other providers) and what was informative. done? “Patient denies…” Level of Function: (ADLs, IADLs, leisure/recreation) Prior Current Future (Anticipated/Desired/Expected) Documentation Outlines and Tips: Initial Examination/Evaluation Last Updated Fall 2024 Page 1 of 4  Medical History and Review of Systems Medical Conditions/Illnesses (Past & Current) Related Injuries (Past & Current) Surgical History If using medical record or intake Medications & Allergies form for this information, need to Family History (if relevant) verify it with the patient when Growth & Development (if relevant) possible. Review of Systems o Presence of symptoms in major body systems Social History Living Environment o Location, layout, co-habitants/family situation, Subjective (continued) adaptive alterations, safety, etc. Occupation o Demand, hours, status, etc. Community Participation o Physical space, obstacles, etc. Health Habits o Substance use, exercise Support & Transportation o Internal & External Assistance Individual Considerations Patient Perception, Beliefs, & Expectations Examination Patient, Family, &/or Caregiver Goals Patient’s reported goals; not formal rehab goals (continued) Systems Review (quick screen: impaired/unimpaired) Cardiopulmonary System Heart rate (bpm) Blood pressure (mmHg) Respiratory rate (rpm Presence of edema or bpm) (description) Integumentary System Pliability Skin color Scars Skin integrity Musculoskeletal System Height (feet/inches) Gross strength Weight (pounds) Gross ROM Gross symmetry/posture Neuromuscular System Gross coordinated movement Objective o Balance, gait, locomotion, transfers, transitions Motor function (motor control and motor learning) Quick screen of sensation, reflexes, etc. Other Communication → Ability to make needs known, Affect → consciousness, orientation (person, Cognition → place, and time), expected emotional Language → & behavioral responses, & learning Learning style → preferences (e.g., learning barriers education needs) Tests and Measures Can include any of the following Any pertinent, specific impairment, functional limitation, subheadings as appropriate: and/or activity measures related to the patient’s condition and/or functional status Documentation Outlines and Tips: Initial Examination/Evaluation Last Updated Fall 2024 Page 2 of 4  Aerobic capacity/endurance Anthropometric characteristics The Guide to PT Practice Tests and Measures section Assistive technology (bottom of linked page) provides the types of impairments, Balance activity limitations, and participation restrictions that may be Circulation associated with each test. It also provides examples of tests Community, social, and civic life within each category. Cranial/peripheral nerve integrity Education life When documenting measurements of any kind, make Environmental factors sure that you include: Gait Body part and side Units of measurement (e.g. mmHg, bpm, degrees) Examination Integumentary integrity Ranges, scales, etc. (e.g. 0-150°, 4/5, 3/2, 5/10) Objective Joint integrity and mobility (continued) (continued) Mental functions Equipment used/level of assistance if indicated Mobility (including locomotion) Additional descriptors for test and measure results Motor function if indicated (ie a patient reported response; Muscle performance observations during the test beyond what makes it Neuromotor development & sensory positive/negative) integration Typically documented categorically Pain Posture Use of tables may organize information better Range of motion Depending on how pain is measured, there are some Reflex integrity specific outcome measures beyond a 0-10 verbal scale Self-care and domestic life that are considered objective outcome measures Sensory integrity Remember to use formal outcome measures where Skeletal integrity appropriate Ventilation and respiration Work life Evaluation/Assessment → Diagnosis → Prognosis Evaluation A process that may result in a narrative statement and/or problem list where information from the Examination (clinical findings) is synthesized and interpreted Can be done utilizing ICF categories Evaluation → Diagnosis & Prognosis Evaluation CPT Codes (Low, Moderate, or High Complexity) Based on personal factors and comorbidities, number of body systems examined, stability of symptoms, and complexity of clinical decision making (resources: 1, 2) Diagnosis Relevant impairments/activity limitations/participation Assessment restrictions are connected creating a PT diagnosis May use terms “consistent with” to tie to a medical diagnosis ICD-10 diagnostic codes (added for billing, not in place of) Prognosis Determination of: Predicted optimal level of improvement in function from a PT standpoint. Estimated amount of time needed to reach that optimal level (sometimes the overall expected outcome listed here may go beyond Plan of Care for the current setting; if so, need to clarify what is anticipated to be achieved during current PT and what will be achieved after) Chances of achieving (Good, Fair, Poor); factors that may attribute to it (e.g. personal and environmental factors) If and how the patient may benefit from PT Documentation Outlines and Tips: Initial Examination/Evaluation Last Updated Fall 2024 Page 3 of 4  Evaluation/Prognosis → Plan of Care (including goals) Goals ABCDE(F) Participation goals Must be related to things recorded in S, O, and A thus far Activity goals Should be coordinated with and be meaningful to patient Impairment goals Activity and participation goals are considered higher level goals compared to impairment goals Impairment goals should always be tied to a function (F) May have short term goals which lead to long term goals Frequency and Duration Typically written in visits per week for a certain number of Evaluation → Prognosis & Plan of Care weeks (x/week for x weeks); sometimes written in just number of anticipated visits Some third-party payers may dictate format Planned Interventions Specificity must be at least at the category level (e.g. CPT code, Guide to PT Practice (9 Plan categories), or other general category), but may be more specific Most of the time do not recommend listing exact interventions or parameters (eg a specific exercise) Recommend tying purpose of intervention to impairment/functional limitation to be addressed. Coordination/Communication → Coordinating care with other health care professionals, PTA’s, family members, etc. Patient related instruction → Technically an intervention, but should occur with every patient and what was discussed should be documented. Consent → Patient consent to carry out the treatment plan needs to be received and documented (consent to do the examination should have been gathered prior to beginning the visit) The plan of care is documented with the discharge disposition in mind (e.g. discharge location, medical equipment, other services, and education) Any treatment performed during the first visit and the response/assessment of that treatment should be documented “after” the entire examination/evaluation note – almost as an addendum treatment note. If you put treatment in with the other objective data (tests and measures), and add assessments of the intervention into the main evaluation assessment, you will be providing intervention information before you read about the necessity of the intervention in the prognosis and plan. See APTA’s Elements of Documentation within the Patient/Client Management Model → Documentation: Initial Examination and Evaluation (direct link) for more detailed explanations and documentation considerations. See the Guide to Physical Therapist Practice for information on specific components of Examination and Evaluation and specific information on categories of Tests and Measures and Interventions. Documentation Outlines and Tips: Initial Examination/Evaluation Last Updated Fall 2024 Page 4 of 4