Understanding Disability Models and Physical Therapy Documentation

The Diagnostic Process: Medical vs. PT Diagnosis

A critical distinction in clinical practice is the difference between a medical diagnosis and a physical therapy diagnosis.

• Medical Diagnosis: This identifies the pathology or the specific health condition (e.g., Osteoarthritis of the knee or a Cerebrovascular Accident/CVA).
• PT Diagnosis: This identifies the impairment and the impact that impairment has on a person's ability to function.

While a doctor diagnoses the disease, the PT diagnoses the functional movement dysfunction. The goal of PT treatment is to minimize these impairments and functional limitations to improve the patient's overall quality of life.

Components of the Initial Examination and Evaluation

The process of gathering information to form a PT diagnosis is known as the Initial Examination and Evaluation. This is a multi-step process performed by the Physical Therapist.

1. Chart Review and Subjective Information

The process begins with a review of the patient's medical history, current medications, and precautions. Following this, the therapist gathers Subjective Information—data provided directly by the patient or their caregivers.

Common Subjective elements include:

• Chief complaint and pain (location, type, and intensity)
• Prior level of functioning
• Home environment and equipment needs
• Patient goals

2. Objective Data and Standardized Tests

The therapist then collects Objective Data through physical testing and measurements. Unlike subjective data, this is measurable and observable.

Common Objective measures include:

• Range of Motion (AROM/PROM) and Strength
• Balance (static and dynamic)
• Posture and Skin Integrity
• Mental Status (orientation and memory)
• Standardized Tests and Measures: These are validated tools used to provide a standard measure of comparison for clinical outcomes, helping to track progress over time.

3. Evaluation and the Plan of Care

After interpreting the subjective and objective data, the therapist performs an Evaluation to determine the PT diagnosis and create a problem list. This leads to the development of the Treatment Plan (also known as the Plan of Care or POC).

The Plan of Care must include:

• Short-Term Goals (STGs) and Long-Term Goals (LTGs): Specific, measurable milestones for the patient.
• Interventions: The specific exercises or treatments to be used.
• Frequency and Duration: How often and for how long the patient will be treated.
• Prognosis: The therapist's professional opinion on the patient's potential to meet the established goals.

Exam Tip: Remember that PTAs do not perform the initial evaluation; they assist the PT during the examination and are primarily responsible for documenting daily treatments and progress.

Documentation Formats and Best Practices

Clinicians use various formats to organize their notes. The most common is the SOAP Note:

• S (Subjective): What the patient tells you.
• O (Objective): What you observe and measure.
• A (Assessment): Your professional interpretation of the data.
• P (Plan): What you intend to do next.

Other formats include Flow Sheets/Checklists for quick scanning of repetitive tasks (like exercise logs) and Narrative notes, which are flexible but less structured.

Professional Standards for Writing

To ensure documentation is professional and legally sound, follow these rules:

Legal Warning: Always remember the golden rule of clinical documentation: "If it isn't written, it didn't happen".

Correction Protocol: Never use white-out or erasable pens. If a mistake is made in a paper record, draw a single line through the error, then date and initial above it.