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As discussed in Chapter 16, after the therapist completes the examination, the process of evaluation begins. As part of the evaluative process, the therapist lists the patient's activity and participation restrictions and impairments discussed in the Evaluation section of the note that relate to physical therapy, as well as environmental factors and personal factors of the patient from the patient interview.
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The Evaluation section of the note provides an opportunity for the therapist to describe the relationships between the examination findings that would not necessarily be obvious to all parties who read patient care notes. After listing the impairments, activity, and participation restrictions, the therapist explains the relationship among these components of function, as well as influences from the patient's physical condition, environmental factors, and personal factors on the patient's ability to function. This documentation is called a diagnostic statement. Diagnostic statements should begin with the patient's activities and participation restrictions and how they relate to the patient's impairments and medical diagnosis. Additional information regarding the effect of co-morbidities and the patient's personal and environmental factors on the patient's activities and participation restrictions should be stated. Often the diagnostic statement consists of more than one sentence.
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This diagnostic process is another process involved in managing the patient that only therapists perform. This important part of the note reflects the therapist's thinking and leads to the final portion of the Assessment portion of the note, the Prognosis, which is covered in Chapter 18.
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The Therapy Diagnosis
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As a portion of the initial evaluation process, a physical therapist writes a therapy diagnosis (sometimes referred to as a physical therapy differential diagnosis). This therapy diagnosis links functional deficits with related impairments through a kinematic or postural description. That is, it describes the impact that activity and participation restrictions and related impairments have on the patient's ability to function in his environment.
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The therapy diagnosis, as a part of the overall diagnostic statement, should be stated in a more informal manner that is easily understood by other professionals and those who make reimbursement decisions who may not have extensive medical education or knowledge. More technical information regarding physical therapy tests and measurements should be listed under the Tests and Measures/Objective part of the note. In your clinical experience, you will notice that there is a wide range of diagnostic statements that vary from informal to technical terminology or language. Part of your responsibility as a clinician is to learn your institution's policy on informal vs. technical language use in diagnostic statements, or whether that choice is at discretion of the individual therapist.
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Most academic instruction is provided using technical terminology. As a student, making the transition from the technical language of your education to the more informal language of day-to-day physical therapy discussions can take some practice. For the purposes of this textbook, ...