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6 Cards in this Set
- Front
- Back
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S
(Subjective)
Name the 2 of 5 items |
1) Reason for Referral- Current health, PMH, hand dominance, medical dx, medications, other clinical test
2) Social History and Participation Prior level of function (PLOF), family/living situation, environment (architectural barriers), projected level care needed after End of Episode of care. Family and caregiver resources: devices and equipment
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S
(Subjective)
Name the 3 of 5 items |
3) Participation Work status, community/leisure/social activity, Psychological function, Cultural Preferences, General Health, Level of physical fitness, Behavorial health risks and family history 4) Activities Quantifiable measurements / Outcome Questionnaires |
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Objectives |
Tests and Measures 1) Systems Review (cardiopulmonary, integumentary, musculoskeletal, neuromuscular)
2) Communication 3) Cognition 4) pain level 5) Objective findings of the examination 6) Standardized Test of Function |
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Assessment / Plan
4 of 8 |
Assessment and Evaluation 1) Summary Statement, 2) Dx 3) Statement of pt's prognosis or potential benefit of from PT 4) Clinical Decision |
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Assessment / Plan
4 of 8 |
Assessment and Evaluation
5) Medical dx 6) ICD 9 code 7) PT Dx (i.e. practice pattern or clinical practice guideline) 8) Differential dx |
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Goals and Plan of Care |
1) Includes freq 2) Expected outcomes/anticipated goals (participation goals, activity goals, impairment goals) 3) Intervention plans 4 Document consent, coordination, communication, and pt instructions. |
