identifies pt health status, problems that may require consultation
What is the most important aspect of the examination?
How do you use your resources during examination?
You use a team approach, utilizing EBP and an adaptable team approach of verbal/non-verbal communication
what is the evaluation?
It is a clinical assessment of the data and interpretation of tests and measures gathered during examination. Uses a problem list of functional limitations, disabilities, and impairments.
What is the definition of the PT diagnosis?
labels of movement dysfunction related to tissue pathology
What is the purpose of the diagnosis?
Find out what level of movement function the person is at and what their movement function goals are. To guide in intervention or referral
Why use classification schemes? Example?
used to generate preferred practice patterns. If a person has spina bifida, that comes with a host of movement disorders that require a specific practice pattern
What clues/tools do you have to develop the diagnosis?
your problem list, lists of medical diagnoses, diagnostic images
what if you can't identify a cluster of dysfunction?
Reexamine/reevaluate, treat the person by changes in symptoms
What is the prognosis?
predicted optimal level of function and the amount of time need to return to that function
Three aspects of a prognosis?
Goals, length of treatment, length of time until healing is complete
Short term goals of prognosis
measurable, specific, step by step process by which you will reach your long term goals. pt/family oriented. Measurable and specific. Linked to impairments, functional limitations, and disability. Must be time specific!
long term goals
same as short but sees through to the end of treatment/intervention
What is the intervention?
Purposeful and skilled interaction, involving effective communication, coordination, documentation, and instruction. must produce changes in patient condition.
components of intervention: Coordination, Communication, Documentation
coordination of care, D/C planning, referrals, documentation, record reviews
Components of the Intervention:Pt/Client-related Instruction
current condition, role of PT, future care, future transitions, maintenance/prevention