Assess

Assessment

The Elements of Patient/Client Management Leading to Optimal Outcomes

DIAGNOSIS

Both the process and the end result of evaluating examination data, which the physical therapist organizes into defined clusters, syndromes, or categories to help determine the prognosis (including the plan of care) and the most appropriate intervention strategies.

PROGNOSIS (INCLUDING PLAN OF CARE)

Determination of the level of optimal improvement that may be attained through intervention and the amount of time required reaching that level. The plan of care specifies the interventions to be used and their timing and frequency.

INTERVENTION

Purposeful and skilled interaction of the physical therapist with patient/client and, if appropriate, with other individuals involved, using various physical therapy procedures and techniques to produce changes in the condition that are consistent with the diagnosis and prognosis. The physical therapist conducts a reexamination to determine changes in patient/client status and to modify or redirect intervention. The decision to reexamine may be based on new clinical findings or on a lack of patient/client progress. The process of reexamination also may identify the need for consultation with or referral to another provider.

OUTCOMES

Results of patient/client management, which include the impact of physical therapy interventions in the following domains: pathology/pathophysiology (disease, disorder, or condition); impairments, functional limitations, and disabilities; risk reduction/prevention; health, wellness, and fitness; societal resources; and patient/client satisfaction.

EXAMINATION

The process of obtaining a history, performing a systems review, and selecting and administering tests and measures to gather data about the patient/client. The initial examination is a comprehensive screening and specific testing process that leads to a diagnostic classification. The examination process also may identify possible problems that require consultation with or referral to another provider.

EVALUATION

A dynamic process in which the physical therapist makes critical judgments based on data gathered during the examination. This process also may identify possible problems that require consultation with or referral to another provider.*

*Adapted with permission from American Physical Therapy Association. Guide to Physical Therapist Practice, rev. ed 2. 2003, Alexandria, VA. Fig. 1-4, p. 35.

Clinical Problem Solving

1. Identify patient/client's symptoms.

2. Determine symptoms to be addressed.

3. Identify characteristics of relevant symptoms.

4. Develop priority list of problems to be assessed.

5. Identify procedures to examine the symptoms.

6. Perform the examination.

7. Interpret the results of the examination (evaluation).

8. Establish diagnosis.

9. Identify goals and plan of treatment.

10. Provide interventions.

11. Evaluate effect of interventions.

12. Modify treatment program as indicated.

Patient/Client Hx

Chief Complaint & Symptom Hx

• Description of onset of Sx

  • Date of onset

  • Mechanism of injury/disease

• Duration of Sx

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