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SOAP - August 7, 2008 10:50:24 AM
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torques
Posts: 59
Joined: July 18, 2008
From: Marion, IN
Status: offline
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Hello All ,
I am curious how manual PT's do their documentation for f/u visits. Maybe you can share your style. I am continually trying to standardize mine. Feel free to comment/advise:(Here is a sample of mine-based on a real patient)
PHYSICAL THERAPY PROGRESS NOTE/RE-EVALUATION
SUBJECTIVE: Patient reports that his back does not hurt as bad during sitting at
work
OBJECTIVE:
Patient's residual musculoskeletal impairment:
- Postural impairment:hypokyphosis thoracic spine, decreased lumbar
lordosis
- Motor function impairment:pain with forward bending and return from
forward bending. Inappropriate lumbar initiation in active sitting,Poor active
lumbopelvic dissociation
- Neuro integrity impairment:(+)NT
- Myofascial tissue impairment:(+)NT
- Joint mobility impairment:slight hypomobility PAIVM lower thoracic and
midlumbar/thoracolumbar, hypermobility lower lumbar with pain provocation on PAIVM
- Muscle performance impairment:transversus abdominis muscle endurance
<5 sec.
Intervention provided this date:
Therapeutic Exercises/Activities:Prone, Press Up x 3 sets of 10,
Quadruped: Pelvic anterior/posterior tilt x 20 reps
Neuromuscular Re-education:Phase I lumbar stabilization:
Quadruped x 10 sec hold x 10 reps-transversus abdominis, lumbar multifidus,
pelvic floor cocontraction; Biomechanical counseling-sitting/postural awareness and correction
Manual Therapy:
Myofascial:
Joint:High velocity, end range, rotational force , lower thoracic (upper on lower segment), prone with pillow under chest; high velocity, end range, upslide/L rotation force midlumbar (upper on lower segment), L sidelying- Type I locking
Modalities:
Exercise Prescription:Phase I stabilization in Quadruped or sitting
every 2 hours, Prone press Up,pelvic tilt 3xdaily as above
ASSESSMENT:
- noted improvement from last visit's impairment list:()
- no noted improvement from last visit's impairment list:(x)
- post treatment response:Tolerate treatment well. Patient showed good
understanding of proper lumbar stabilization and postural correction in
sitting; segmental hypomobility midlumbar/midthoracic resolved post treatment; motor control in active sitting improved.
Long Term Goal (Outcome):
The patient reports a clinically meaningful improvement in the
patient's ability to perform following activities with minimal
provocation of symptoms:* Initial Score
1.lifting 3/10
2.sitting at work 3/10
3.mowing lawn 3/10
*(Patient Identified Problem List/Patient-Specific Functional Scale-11 point
scale with 10-no difficulty,0-unable to perform the task)
SHORT TERM GOALS/STRATEGIES:
Improve posture to WNL exhibited by correction/improvement of:hypokyphosis/decrease lumbar lordosis
Improve active range of motion of following joints to WFL:painfree trunk forwardbending
Improve passive mobility of following joint/s to WNL:midthoracic, midlumbar segments
Decrease tissue reactivity of following myofascial tissues to WFL:lower lumbar spine segment and paraspinals
Improve extensibility of following myofascial structure/s to normal
limits:tight bilateral hamstring, gluteal muscle, lumbar paraspinal muscles,
bilateral hip flexors
Improve muscle strength/endurance of following muscles to normal
limits:lumbar stabilization muscles
PLAN:
- continue or upgrade/progress current goals and intervention:(Yes)
- Short term Goals and/or Interventions are modified:(No)
- Patient is dicharged from PT (No).
Reason:
Tentative completion of plan of treatment:8/28/08
----------------------------------------------------------------------------
Acronyms:
PIVM-Passive intervertebral Motion
PAIVM-Passive accessory intervertebral Motion
PPIVM-Passive physiologic intervertebral Motion
FB/BB-Forward bending/Backward bending
SBR/SBL-sidebending right/sidebending left
RR/RL-Rotation right/Rotation left
TrA/LM-Transversus Abdominis/Lumbar Multifidus
Looks like a lot but I do my notes in the computer so I do lots of cuts and paste and change stuff for my succeeding notes. I spend maybe 5 min tops each note.
Julius Quezon PT MTC CPed
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RE: SOAP - August 7, 2008 3:25:16 PM
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Shill
Posts: 1097
Joined: February 13, 2003
From: Madison WI USA
Status: offline
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A few thoughts:
His back does not hurt as bad. What does this mean? Does he now hurt at a 9/10, or a 1/10? Your descriptions are more meaningful when quantified. Its also a medicare requirement to rate pain at each visit.
You probably should elaborate a bit more on why this patient needs your skillled care. Otherwise, it can look like you are just throwing exercises at the patient. Rationale for the movements and the manual therapy can show why this is skilled care. It can be stated in a sentence or two.
Your goals are not completely functional or truly measurable in some cases. What is normal myofascial extensibility, and how will it help this patient with a particular function? How will the payor know when the lumbar stabilization muscles are returned to "normal"?
We as therapists know that trunk forward bending being WFL means that the patient can now reach down to pick something up. Insurers need that information fed to them with a spoon. As you are computerizing your templates, you could easily add a sentence of ...."to improve ability to reach to the ground and retrieve a pair of shoes with no pain higher than 2/10" or words to that effect.
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