Chapter 12: The Patient/Client Management Format: Writing Systems Review and Tests and Measures

Introduction

Systems Review is the beginning of the hands-on part of the examination. It is a limited set of tests and measures that the therapist uses to plan the more detailed tests and measures that the therapist will perform on the patient.

Tests and Measures is the section of the Patient/Client Management Note in which the therapist records the results of more detailed tests and measures performed and observations of the patient. Tests and measures are measurable or observable and contribute to the evaluation of the patient and determination of the diagnosis, prognosis, and plan of care. Good tests and measures are valid and reliable. Tests and measures are also repeatable so you can compare them with tests and measures recorded in the future to determine the effectiveness of the selected therapeutic interventions. Tests and measures thus serve as comparative data as the patient's progress is monitored and re-evaluated.^1,2

The Systems Review

The Systems Review is a limited set of tests and measures that examine briefly the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems, and the patient's communication, affect, cognition, learning style, and education needs. This is the beginning of the hands-on part of the examination. The information in the Systems Review makes up a separate part of the note between History and Tests and Measures. At some facilities, the Systems Review information is included in the Tests and Measures part of the note. Often, this information is recorded on a form. For the purposes of this textbook, you are to record the information on a form. When you record information on a form, refer to the form in a separate Systems Review section of the note listed prior to the Tests and Measures section.

The Systems Review should include the following information:

• Cardiovascular and pulmonary systems: all completed in a resting state: heart rate, respiratory rate, blood pressure, presence of edema

• Integumentary system: skin pliability or texture, skin integrity, scars, skin color

• Musculoskeletal system: gross symmetry during standing, sitting, and activities; gross range of motion; gross strength; height and weight

• Neuromuscular system: gross coordinated movement (balance, gait, locomotion, transfers, transitions), gross motor function (motor control, motor learning)

• Communication and language: the ability to make needs known

• Affect: the patient responds with expected emotional/behavioral reactions

• Cognition: consciousness, orientation to person, place, and time

• Learning style: learning preferences (listening, reading, pictures, demonstration, other), learning barriers, and education needs

Figure 12-1 shows an example of a form that can be used to record the Systems Review:

Note that there is a Comments section for each category on the form. If any portions of the Systems Review ...