Physical Therapy Documentation by unknow

Author:unknow
Language: eng
Format: epub
ISBN: 6237044
Publisher: SLACK, Incorporated

Objective Data Systems Review

Tests and Measures

Measuring Impairment

Measuring Function ♦ Generic Versus Specific Measures

♦ Patient Performance Versus Self-Report

Describing Interventions

Counting Minutes

CHAPTER OBJECTIVES

Upon completion of this chapter, the reader will be able to:

List sources of information for historical data

Differentiate between the Problem and Subjective sections of the note

Identify types of data that should be recorded in the Problem and Subjective sections of a SOAP note

Discuss how historical data inform the clinical decision-making process

When given information collected from a patient history, organize the information in logically sequenced Problem and Subjective sections

Identify types of data that should be recorded in the Objective section of the SOAP note

Discuss the purpose of the systems review

Discuss how objective data are used to inform the clinical decision-making process

Differentiate between measurements of impairments of body structure/function and measurements of functional activity limitations

Discuss characteristics of tests and measures (general vs specific and self-report vs performance based)

When provided data collected during a patient examination, arrange the data into a logically sequenced Objective section

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