Interpreting Initial eval

• 7th question during the review of initial eval

  Are there any other special issues I need to keep in mind as I work with the pt
• 6th question during the review of initial eval

  Are there any contraindications or precautions I need to keep in mind as I work with the patient?
• 5th question during the review of initial eval

  what is the pts prognosis
• 4th question during the review of initial eval

  What is the pt's diagnosis
• 3rd question during review of initial eval

  what is the patient's current status regarding this condition?

  What are the PT and pt goals regarding this condition?
• 2nd question during review of initial eval

  What problem is the intervention addressing
• 1st question during review of initial eval

  What intervention does the PT want me to provide
• Plan


  Plan collaboration, patient education, procedural interventions, frequency/ duration, treatment progression, plans for testing and retesting, equipment needs, referral to other services, anticipated discharge
• Assessment


  PT's interpretation of S&O, goals, identification of impairments and limitations, PT diagnosis, prognosis/ rehab potential, justification of goals/ treatment plan, explanation of difficulties obtaining S&O data, recommendation for further testing, treatment, or referrals
• Objective


  Info gathered through tests, measures, and observations, interventions provided, pt response to interventions provided, pt education
• Subjective


  Pt's current medical history, past medical history, symptoms of complaint, factors that cause symptoms of complaints, patient's prior level of function, pt lifestyle/ occupation/ societal/ roles, pt goals
• Problem or Health Condition


  Patient's chief complaint, medical diagnosis, contraindications/ precautions, physical therapy diagnosis, referral for PT services, functional limitations, info from medical records
• Element: Outcomes

  Objective/ Assessment
• Element: Intervention

  Objective/ Plan
• Element: Prognosis

  Assessment
• Element: Diagnosis

  Assessment
• Element: Evaluation

  Assessment
• Element: Test and Measures

  Objective
• Element: Exam systems review

  Objective
• Element: Exam- history

  Problem, subjective
• 6 components of patient management

  Exam, eval, diagnosis, prognosis, intervention, and outcomes
• Initial eval used by PTA

  As a reference, provide framework for patient related activity
• Initial eval note contains

  Clear picture of patient, diagnosis, prognosis, anticipated goals, and POC
• Re-eval/ discharge note

  Performed by PT; PTA can assist in data collection
• Progress note/ report


  Summary of PT care to date and should be written by PT, PTA can assist in data collection, continued medical necessity, not billed as re-eval
• Daily/ treatment note

  Completed by individual providing interventions