The therapist writes the Prognosis after completing the Examination, Evaluation, and Diagnosis. The therapist looks at the severity of the patient's activity and participation restrictions, impairments, the patient goals, patient and environmental factors, and predicts a level of improvement in activities and participation and the total amount of time needed to reach the level.1
The Prognosis can be a portion of the Assessment (A) or Plan of Care (P) sections of a note. This varies by individual practice setting for a variety of reasons, including individual site preference and documentation program format. Check with your individual place of employment or clinical site to determine their documentation preference and/or policy for documenting the Prognosis portion of the note. For the purposes of this textbook, the Prognosis is the last portion of the Assessment (A) portion of the SOAP Note and is a separate section of the Patient/Client Management Note.
Case Patient: Mr. Torres
Location: Outpatient facility Medical Diagnosis: Grade I tear in right supraspinatus muscle (rotator cuff).
EVALUATION: Impairments: ↓ ® shoulder AROM, pain ® shoulder, weakness ® rotator cuff muscles. Activity & Participation Restrictions: Pt cannot reach into overhead cabinets or shelves or lift heavy tools (greater than 50# at times) needed for his job as a tree trimmer c̄ his ® UE. Cannot tolerate use of power tools c̄ his dominant ® UE. Personal factors: States he is motivated to return to work ASAP; no absences from work until current injury. Environmental Factors: Cannot return to full duty until he is able to lift tools (greater than 50#), operate equipment safely using bilat. UEs, and pass fit test; employer supportive of light duty.
DIAGNOSIS: The patient's ↓ ® shoulder AROM & strength are preventing him from being able to reach upward with his dominant arm & lift heavy tools (greater than 50#) to complete tasks required for him to return to full-duty work as a tree trimmer.
PROGNOSIS: Pt. has excellent potential to meet expected outcomes of therapy due to his excellent motivation to return to work, young age, no prior injury to the ® shoulder, & overall good physical conditioning prior to injury. Expected to progress to being able to successfully & safely complete light duty tasks for work in 3 wks & return to full duty in 6 wks.
The Prognosis is the part of the patient management process that only therapists write. As part of a discussion of the Prognosis, several kinds of information may be addressed. Each category of information is briefly described in the following sections.1,2
Factors Influencing the Prognosis
In this section of the note, the therapist describes the environmental and personal factors that may influence the prognosis. These factors can include the living/work environment, the patient's condition before the onset of the current therapy diagnosis, and any current illnesses or chronic medical conditions ...