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The first process that a physical therapist performs when seeing a patient is an examination of the patient. The examination consists of a patient interview and hands-on examination of the patient. In the Patient/Client Management Note, the examination is documented in three sections. The first section is titled History and includes a subsection called Review of Systems. The second section is titled Review of Systems, and the third is Tests and Measures.1
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Before continuing, it is important to avoid confusion between a Review of Systems (described below) and the Systems Review (described in Chapter 12). The Review of Systems is a review of the current medical conditions of the patient. The Systems Review is a limited set of hands-on tests and measures performed to determine the further direction of the examination.
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The following types of information are to be entered in the History section:
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Demographic information about the patient (identifying information): The patient's name, address, admission date, date of birth, biological sex, dominant hand, race, ethnicity, language, education level, advance directive preferences, referral source, and reasons for referral to therapy such as medical diagnosis.
Current conditions/Chief concerns: In some facilities, you may see this described as “Chief Complaints.” This includes the onset date of the problem, any incident that caused or contributed to the onset of the problem, history of similar problems, how the patient is caring for the problem, what makes the problem better and worse, and any other practitioner the patient is seeing for the problem.
Prior and current level of function: Information describing the patient's level of function, including activities and participation, prior to the most recent onset of the current condition or complaints. If the patient has a chronic condition, this information should include the level of function prior to the most recent onset or exacerbation of symptoms. This subsection of the history also includes the patient's current level of function, including activity limitations and participation restrictions, and information on everything from bed mobility, transfers, gait, self-care, and home management to community and work activities that apply to the patient's current situation or condition.
Patient goals: The patient and sometimes family goals for therapy as told to the therapist by the patient or family/caretaker, in cases where the patient cannot speak for himself.
Social history: Cultural and religious beliefs that might affect care, the person(s) with whom the patient lived prior to admission and will live after discharge, social support available to the patient now and that will be available after discharge.
Employment status: Whether the patient works fulltime or part-time, inside or outside of the home, is retired or is a student, and any special physical job requirements that the patient must be able to complete to return to his place of employment, such as needing to be able to lift at least 100 pounds.
Physical environment and available resources: Assistive devices and equipment ...