Foundation of the Physical Therapy Healthcare Process (Part 6)
January 25th 2008 12:03
The Evaluation Process
After taking the patient’s history, we then proceed with the physical examination. The information we gained from observation and correct history taking shall guide the sequence of our evaluation. And doing the correct sequence of an examination is a skill, which we develop through repeated practice.
The details below show how a physical therapy evaluation commences (Pierson, 1999):
Subjective Information
• Patient’s concept of his/her chief complaint or problem
• Patient’s description of the progression or regression of the condition over a period of time
• General health of the patient
• HPI, PMHx, Family History (FHx), etc.
• Patient’s description of the results of any previous treatment for a similar condition, complaint, or problem
• Patient’s occupation, lifestyle, recreational activities, social interactions, goals, needs, and values
Objective Information
• Observe the patient’s:
1. general appearance, body build, or configuration and any deformities or absence of any body par
2. posture as he/she stands, sits, walks
3. skin condition and its appearance
4. locomotion or mobility
5. use of assistive devices, ambulation aids, orthoses, prostheses, bandages, sling, or casts
6. balance and stability
7. coordination and motor control
• Palpate the patient’s:
1. skin and subcutaneous tissue to determine its texture, temperature, flexibility, and pain response
2. muscles, tendons, ligaments for their tone, pain response, bulk, composition, strength, stability/laxity
3. joints to determine any swelling, change in shape, tenderness, amount of joint space, and pain response
4. skeletal components
5. arterial pulses to establish rate, force, presence/absence, and rhythm
• Assess the patient’s muscle strength, range of motion, end feel, sensorium, functional activities and abilities
• Evaluate cardiopulmonary functions by measuring vital signs before, during, and after activities
• Perform diagnostic and special tests
We need to understand that every measure in an evaluation does require specificity and detailed explanation of its significance and finding. The evaluation shall help us identify the current problems, and even the potential problem a patient may encounter later on. The findings stated in our evaluation can help prognosticate the patient’s condition and come up with managements that are very much individualized or personalized.
After examining a patient, we then formulate an outline of our assessment of the patient’s condition. The assessment part of our documentation includes a list of problems we discovered our patient has. The outline also includes the goals we have set for our patient. And in goal setting, we create two sets of goals: the short-term and the long-term goals. Short-term goals are goals that are achievable within days or weeks, while long-term goals are goals that may be achievable within months. In addition, long-term goals may be goals that should be carried out in a lifetime.
After taking the patient’s history, we then proceed with the physical examination. The information we gained from observation and correct history taking shall guide the sequence of our evaluation. And doing the correct sequence of an examination is a skill, which we develop through repeated practice.
The details below show how a physical therapy evaluation commences (Pierson, 1999):
Subjective Information
• Patient’s concept of his/her chief complaint or problem
• Patient’s description of the progression or regression of the condition over a period of time
• HPI, PMHx, Family History (FHx), etc.
• Patient’s description of the results of any previous treatment for a similar condition, complaint, or problem
• Patient’s occupation, lifestyle, recreational activities, social interactions, goals, needs, and values
Objective Information
• Observe the patient’s:
1. general appearance, body build, or configuration and any deformities or absence of any body par
2. posture as he/she stands, sits, walks
3. skin condition and its appearance
4. locomotion or mobility
5. use of assistive devices, ambulation aids, orthoses, prostheses, bandages, sling, or casts
6. balance and stability
7. coordination and motor control
• Palpate the patient’s:
1. skin and subcutaneous tissue to determine its texture, temperature, flexibility, and pain response
2. muscles, tendons, ligaments for their tone, pain response, bulk, composition, strength, stability/laxity
3. joints to determine any swelling, change in shape, tenderness, amount of joint space, and pain response
4. skeletal components
5. arterial pulses to establish rate, force, presence/absence, and rhythm
• Evaluate cardiopulmonary functions by measuring vital signs before, during, and after activities
• Perform diagnostic and special tests
We need to understand that every measure in an evaluation does require specificity and detailed explanation of its significance and finding. The evaluation shall help us identify the current problems, and even the potential problem a patient may encounter later on. The findings stated in our evaluation can help prognosticate the patient’s condition and come up with managements that are very much individualized or personalized.
After examining a patient, we then formulate an outline of our assessment of the patient’s condition. The assessment part of our documentation includes a list of problems we discovered our patient has. The outline also includes the goals we have set for our patient. And in goal setting, we create two sets of goals: the short-term and the long-term goals. Short-term goals are goals that are achievable within days or weeks, while long-term goals are goals that may be achievable within months. In addition, long-term goals may be goals that should be carried out in a lifetime.
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