Assessment and Plan

8/12/2019 Assessment and Plan

1/153

What have I accomplished with my

patient so far?

I have taken his/her:

Identifying Data / Patient Demographics

Who is the patient?

Does he/she belong in a certain diagnostic group

basing on the demographic data?

Subjective Data

What is his/her problem as he/she reports it? What else do I know of him/her as he/she says?

Objective Data

How does his/her problem present itself clinically

as I have observed?


2/153

What else do I need to do???

I need to analyze what I know so far about

my patient and his/her case, including:

Interpret the information recorded.

Identify factors that are not within normal

limits for people in the same age range as the

patient.

From these factors, formulate a list of thepatients problems, including functional

limitations, impairments, and disabilities.


3/153


I need to formulate impression(s) of the

patients problems and conditions,

including:

Does he/she fit in to a particular diagnostic

label?

If so, what?

If not, how do I classify him/her?


4/153


5/153


I need to identify

methods/techniques/treatments within the

bounds of my knowledge and expertise

that I can use/perform on my patient. I need to decide, together with my patient,

the specific

methods/techniques/treatments that will beperformed on him/her while considering

many things on both our sides (safety,

cost-effectiveness, etc.).


6/153


I need to treat the patient with the

methods/techniques/interventions that we

both have decided on.


7/153


8/153

But how do I go further???

I need to know how to:

Evaluate

Diagnose

Make a prognosis

Identify a plan of care, including appropriate

intervention(s)

Re-evaluate


9/153

The Patient/ClientAssessment

Elements of Patient/ClientManagement in Assessment

Documenting Assessment Content ina SOAP Format


10/153

Elements of Patient/Client

Management in Assessment 3 elements of patient/client management

are incorporated in formulating the

Assessment portion.

These are:

Evaluation

Diagnosis

Prognosis


11/153


Management in Assessment Evaluation

The organization and interpretation of data.

Physical therapists make evaluations (clinical

judgments) that are based on the data

gathered from the examination (history,

systems review, and tests and measures) that

are synthesized to establish the diagnosis,prognosis, and plan of care.


12/153



Factors that influence the complexity of the

evaluation process include:

Clinical findings

Extent of loss of function

Social considerations

Overall physical function and health status


13/153


14/153



Physical therapists also consider:

Severity and complexity of the current impairments

and the probability of prolonged impairment,functional limitation, and disability

The living environment

Potential discharge destinations

Social support


15/153



Evaluation encompasses all sections in the

Assessment portion of a SOAP note but is

mainly the process in considering thesignificant findings (Problem List).


16/153


Management in Assessment Diagnosis

The application of a label.

Physical therapists typically use diagnostic

labels that identify the impact of a condition

on function at the level of the system

(especially the movement system) and at the

level of the whole person.


17/153



The assigning of a diagnostic label through

the classification of a patient/client within a

specific practice pattern is a decision reachedas a result of a systematic process.


18/153


19/153



The diagnostic process enables the physical

therapist to verify the individual needs of each

patient/client to similar individuals who areclassified in the same pattern while also

capturing the unique concerns of the

patient/client in meeting those needs in a

particular sociocultural and physical

environment.


20/153



If the diagnostic process does not yield an

identifiable cluster (e.g., of signs or

symptoms, impairments, functional limitations,or disabilities), syndrome, or category, the

physical therapist may administer

interventions for the alleviation of symptoms

and remediation of impairments.


21/153



As in all other cases, the physical therapist is

guided by patient/client responses to those

interventions and may determine that areexamination is in order and proceed

accordingly.


22/153



The objective of the physical therapists

diagnostic process is the identification of

discrepancies that exist between the level offunction that is desired by the patient/client

and the capacity of the patient/client to

achieve that level.


23/153



In carrying out the diagnostic process,

physical therapists may need to obtain

additional information (including diagnosticlabels) from other professionals. In addition,

as the diagnostic process continues, physical

therapists may identify findings that should be

shared with other professionals (including

referral sources) to ensure optimal care.


24/153



If the diagnostic process reveals findings that

are outside the scope of the physical

therapists knowledge, experience, orexpertise, the physical therapist refers the

patient/client to an appropriate practitioner.


25/153



Making a diagnosis requires the clinician to

collect and sort data into categories according

to a classification scheme relevant to theclinician who is making the diagnosis.

These classification schemes should meet

certain criteria.


26/153



Criteria for classification schemes:

Classification schemes must be consistent with the

boundaries placed on the profession by law (whichmay regulate the application of certain types of

diagnostic categories) and by society (which grants

approval for managing specific types of problems

and conditions). The test and measures necessary for confirming

the diagnosis must be within the legal purview of

the health care professional.


27/153



Criteria for classification schemes:

The label used to categorize a condition should

describe the problem in a way that directs theselection of interventions toward those

interventions that are within the legal purview of

the health care professional who is making the

diagnosis.


28/153



The preferred practice patterns in APTAs

Guide to Physical Therapist Practice describe

the management of patients who are groupedby clusters of impairments that commonly

occur together, some of which are associated

with health conditions that impede optimal

function.


29/153



Each pattern represents a diagnostic

classification.

The pattern title therefore reflects thediagnosisor impairment classification

made by the physical therapist.

The diagnosis may or may not be associatedwith a health condition for patients/clients who

are classified into that pattern.


30/153



The physical therapist uses the classification

scheme of the preferred practice patterns to

complete a diagnostic process that beginswith the collection of data (examination),

proceeds through the organization and

interpretation of data (evaluation), and

culminates in the application of a label

(diagnosis).


31/153



Diagnostic labels are placed in the

Impressions/Summary section of the

Assessment portion of a SOAP note.


32/153



Physical Therapy Diagnostic Classifications:

Musculoskeletal

Primary prevention/risk reduction for skeletaldemineralization

Impaired posture

Impaired muscle performance

Impaired joint mobility, motor function, muscle

performance, and range of motion associated with

connective tissue dysfunction


performance, and range of motion associated with

localized inflammation


33/153




Musculoskeletal

Impaired joint mobility, motor function, muscleperformance, range of motion, and reflex integrity

associated with spinal disorders

Impaired joint mobility, muscle performance, and range

of motion associated with fracture

Impaired joint mobility, motor function, muscleperformance, and range of motion associated with joint

arthroplasty


performance, and range of motion associated with bony

or soft tissue surgery


34/153




Musculoskeletal

Impaired motor function, muscle performance, range ofmotion, gait, locomotion, and balance associated with

amputation


35/153




Neuromuscular

Primary prevention/risk reduction for loss of balance andfalling

Impaired neuromotor development

Impaired motor function and sensory integrity associated

with nonprogressive disorders of the central nervous

systemcongenital origin or acquired in infancy orchildhood


with nonprogressive disorders of the central nervous

systemacquired in infancy or childhood


36/153




Neuromuscular

Impaired motor function and sensory integrity associatedwith nonprogressive disorders of the central nervous

systemcongenital origin or acquired in adolescence or

adulthood


with progressive disorders of the central nervous system Impaired peripheral nerve integrity and muscle

performance associated with peripheral nerve injury


with acute or chronic polyneuropathies


37/153




Neuromuscular

Impaired motor function, peripheral nerve integrity, andsensory integrity associated with nonprogressive

disorders of the spinal cord

Impaired arousal, range of motion, and motor control

associated with coma, near coma, or vegetative state


38/153




Cardiovascular/Pulmonary

Primary prevention/risk reduction forcardiovascular/pulmonary disorders

Impaired aerobic capacity/endurance associated with

deconditioning

Impaired ventilation, respiration/gas exchange and

aerobic capacity/endurance associated with airwayclearance dysfunction

Impaired aerobic capacity/endurance associated with

cardiovascular pump dysfunction or failure


39/153




Cardiovascular/Pulmonary

Impaired ventilation and respiration/gas exchangeassociated with ventilatory pump dysfunction or failure

Impaired ventilation and respiration/gas exchange

associated with respiratory failure

Impaired ventilation, respiration/gas exchange and

aerobic capacity/endurance associated with respiratoryfailure in the neonate

Impaired circulation and anthropometric dimensions

associated with lymphatic system disorders

El f P i /Cli


40/153




Integumentary

Primary prevention/risk reduction for integumentarydisorders

Impaired integumentary integrity associated with

superficial skin involvement

Impaired integumentary integrity associated with partial-

thickness skin involvement and scar formation

Impaired integumentary integrity associated with full-

thickness skin involvement and scar formation

Impaired integumentary integrity associated with skin

involvement extending into fascia, muscle, or bone and

scar formation


41/153

El t f P ti t/Cli t


42/153


Management in Assessment Prognosis (including Plan of Care)

Plan of Care

Consists of statements that specify the anticipated

goals and expected outcomes, predicted level ofoptimal improvement, specific interventions to be

used, and proposed duration and frequency of the

interventions that are required to reach the

anticipated goals and expected outcomes. Therefore describes:

Specific patient/client management (Interventions)

Timing for patient/client management for the episode of

physical therapy care (Goals)

El t f P ti t/Cli t


43/153



Plan of Care

The plan of care is the culmination of the

examination, diagnostic, and prognosticprocesses.

It is established in collaboration with the

patient/client and is based on the data gathered

from the history, systems review, and tests andmeasures and on the diagnosis determined by the

physical therapist.

El t f P ti t/Cli t


44/153



Plan of Care

In designing the plan of care, the physical therapist

analyzes and integrates the clinical implications ofthe severity, complexity, and acuity of the

pathology/pathophysiology (disease, disorder, or

condition), the impairments, the functional

limitations, and the disabilities to establish theprognosis and prediction about the likelihood of

achieving the anticipated goals and expected

outcomes.

El t f P ti t/Cli t


45/153



Plan of Care

The plan of care identifies anticipated goals and

expected outcomes, taking into consideration theexpectations of the patient/client and appropriate

others.

If required, the anticipated goals and expected outcomes

may be expressed as short-term and long-term goals.

El t f P ti t/Cli t


46/153



Plan of CareAnticipated goals and expected outcomes are the

intended results of patient/client management andindicate the changes in impairments, functional

limitations, and disabilities and the changes in health,

wellness, and fitness needs that are expected as the

result of implementing the plan of care.

The anticipated goals and expected outcomes also

address risk reduction, prevention, impact on societal

resources, and patient/client satisfaction.

The anticipated goals and expected outcomes in the plan

should be measurable and time limited.

El t f P ti t/Cli t


47/153



Plan of Care

The plan of care includes the anticipated discharge

plans. In consultation with appropriate individuals, the physical

therapist plans for discharge and provides for appropriate

follow-up or referral.

The primary criterion for discharge is the achievement of

anticipated goals and expected outcomes.

When physical therapy services are terminated prior to

achievement of anticipated goals and expected

outcomes, patient/client status and the rationale for

termination are documented.


48/153

El t f P ti t/Cli t


49/153



Plan of Care

Thus, Plan of Care encompasses the Assessment

and Plan portions of a SOAP note. Special Note:

In the course of examining the patient/client and

establishing the diagnosis and prognosis, the physical

therapist may find evidence of physical abuse or

domestic violence.

Universal screening for domestic violence is

increasingly becoming a statutory requirement.

D ti A t


50/153

Documenting Assessment

Content in a SOAP Format The Assessment portion of a SOAP note

includes 4 sections that, together, provide

the reader with the therapists reasoning

for goals and treatment. Problem List

Long-Term Goals/Expected Functional

Outcomes Short-Term Goals

Impressions/Summary

D ti A t


51/153


Content in a SOAP Format Problem List

Provides a list of the major problems as

written in the Subjective and Objective parts

of a SOAP note.

Doc menting Assessment


52/153



Some facilities do not include this portion but

is becoming a reference point for other

healthcare professionals, third-party payers,and others who read the medical record and

need a quick overview of the patients

physical therapy problems, just as physical

therapists look to physicians impressions fora summary of the patients significant medical

problems.



53/153



Relationships to other portions of the SOAP

note:

Subjective and Objective The problem list includes the major areas that were not

WNL when the Subjective interview and Objective testing

were performed.

Long-Term Goals/Expected Functional Outcomes Usually each problem listed in a SOAP note is coveredby a long-term goal/expected functional outcome.



54/153



Steps to formulating the Problem List: (Prerequisite) Write the S and O portions of the

note.

Review the S and O portions of the note, jottingdown or highlighting findings that are not WNL andthat can be influenced or changed by physicaltherapy intervention.

Medical or psychiatric problems do not belong in thephysical therapy problem list.

However, discussion as to how medical or psychiatricproblems affect the patients potential or actualperformance in physical therapy should be included inthe Impressions/Summary part of the Assessment

portion of the note.



55/153



Steps to formulating the Problem List:

Set priorities as to which problem is the most

important, the next important, and so forth. Involves judgment on the part of the physical therapist.

List the physical therapy problems in order of

priority.

List in functional terms, if possible, and in a generalmanner, since this list is a summary of the more specific

details included under S and O.


56/153



57/153


Content in a SOAP Format Long-Term Goals/Expected Functional

Outcomes

State the final product to be achieved by

physical therapy. Once the problem list is established, the

patients long-term goals are set.



58/153



Outcomes

Reasons for writing goals:

To help the physical therapist plan treatment tomeet the specific needs and problems of a patient

To prioritize treatment and measure effectiveness

To assist with monitoring cost effectiveness (for

purposes of third-party payment)

To communicate the therapy goals for a patient to

other healthcare professionals



59/153



Outcomes

The structure of a goal (ABCDs of goal

setting): Audience

Behavior

Condition

Degree



60/153



Outcomes


setting): Audience

Who will exhibit the skill?

Almost always the patient is the audience.

Can also be a family member or the patient with a familymember.

NEVER the physical therapist.

Goals are patient-oriented, not therapist oriented.



61/153



Outcomes


setting): Behavior

What will the audience do?

Always a verb, often followed by the object of the

behavior. Frequently, as a LTG, is a functional behavior, the object

of the behavior must be something that can be measured

or described accurately so that the physical therapist can

document when goals are achieved.



62/153



Outcomes


setting): Behavior

Always stated using action verbs.

Be or know are not acceptable.

Demonstrate, list, and state are acceptable.



63/153



Outcomes


setting): Condition

Under what circumstances or conditions?

The position, the equipment, and so forth that must be

provided or be available for the patient to perform thebehavior.



64/153



Outcomes


setting): Degree

How well will the behavior be done?

The specific amount of improvement to be seen.

Usually the longest portion of a goal.



65/153



Outcomes


setting): Degree Requirements as to degree:

The degree of performance must be realistic,measurable, or observable.

Must name a specific time span in which the goal willbe achieved. (Needs clinical experience todetermine)

Must be expressed in terms of function, whenpossible. (Not required in some facilities but allowsother readers to understand the rationale behind the

goal)



66/153



Outcomes


setting): Degree

Example:

Number of feet

Number of repetitions Muscle grades

Degrees of ROM.



67/153



Outcomes

Criteria for revision of LTG:

The patients condition changes and will not allowprogression to the functional level originally set.

The patients condition changes and will allow

progression beyond the functional level originally

set. The time span set is no longer appropriate and

should be revised.



68/153



Outcomes


note: Problem List

Usually, a LTG may be set for each problem.

Acceptable if one LTG may address several problems.

Important to consider several aspects in the patientinterview (S portion) when setting LTG.

Short-Term Goals

STG are written as steps toward achieving LTG.


69/153


70/153


71/153


72/153



73/153


Content in a SOAP Format Short-Term Goals

Interim steps along the way to achieving LTG.

Once LTG are determined, STG are set.

Structure of STG is same as to LTG (ABCDsof goal setting).

Criteria for revision of STG:

Time period mentioned in a previous STG haspassed.

The patient has achieved the STG.



74/153


Content in a SOAP Format Short-Term Goals


note:

Long-Term Goals/Expected Functional Outcomes STG are based on the determined LTG.

Plan

When a treatment plan is set up, some sort of treatment

to work toward each of the STG must be included. STG in FOR:

Facilities differ in use of STG in FOR.


75/153



76/153


Content in a SOAP Format

Impressions/Summary

Part of the Assessment portion of a SOAP

note for drawing correlations in the S, O, A,

and P potions of the note and justifyingdecisions for goals and treatment plan.



77/153



Impressions/Summary

Some of the following items may be noted in

this part:

Inconsistencies Justification for the goals set, the treatment plan,

and/or clarification of the problem

Discussion of the patients progress in physical

therapy Patients rehabilitation potential



78/153



Impressions/Summary

Some of the following items may be noted in

this part:

Difficulty in obtaining information Suggestion of further testing/treatment needed

Physical therapy diagnosis

Other


79/153


80/153

The Treatment Plan


Management in Planning forIntervention

Treatment Planning

Writing Plan Content in a SOAPFormat

Evaluation and Monitoring of theInitial Plan

Elements of Patient/ClientM i Pl i f


81/153

Management in Planning for

Intervention Two elements of patient/client

management are incorporated in

formulating the Plan portion.

These are: Prognosis (specifically Plan of Care)

Intervention



82/153


Management in Planning

Prognosis (specifically Plan of Care)

Discussed in the Assessment portion



83/153



Intervention

The purposeful interaction of the physical

therapist and the patient/client and, when

appropriate, with other individuals involved inpatient/client care, using various physical

therapy procedures and techniques to

produce changes in the condition that are

consistent with the diagnosis and prognosis.


84/153



85/153



Intervention

The use of procedural interventions, however,

varies because those interventions are

selected, applied, or modified according toexamination and reexamination findings and

the anticipated goals and expected outcomes

for a particular patient/client in a specific

diagnostic group.



86/153



Intervention

Physical therapist intervention encourages

functional independence, emphasizes

patient/client-related instruction, andpromotes proactive, wellness-oriented

lifestyles.

Through appropriate education and instruction, the

patient/client is encouraged to develop habits thatwill maintain or improve function, prevent

recurrence of problems, and promote health,

wellness, and fitness.



87/153


Intervention

Components

Coordination, Communication, and Documentation

Patient/client-related Instruction Procedural Interventions



88/153


Intervention

Components


Administrative and supportive processes intended toensure that patients/clients receive appropriate,

comprehensive, efficient, and effective quality of care

from admission through discharge



89/153


Intervention

Components


Coordination the working together of all parties involved with the

patient/client

Communication

the exchange of information

Documentation

any entry into the patient/client record that identifies

the care or service provided



90/153


Intervention

Components


Physical therapists are responsible forcoordination, communication, and documentation across

all settings for all patients/clients.



91/153


Intervention

Components


Administrative and support processes may include: addressing required functions, such as

advanced care directives, individualized

educational plans (lEPs), or individualized family

service plans (IFSPs), informed consent , and

mandatory communication and reporting (e.g.,patient advocacy and abuse reporting)

admission and discharge planning

case management



92/153


Intervention

Components


Administrative and support processes may include: collaboration and coordination with agencies

communication across settings

cost-effective resource utilization

data collection, analysis, and reporting

documentation across settings

interdisciplinary teamwork

referrals to other professionals or resources



93/153


Intervention Components

Patient/client-related Instruction

The process of informing, educating, or trainingpatients/clients families, significant others, and

caregivers intended to promote and optimize physical

therapy services.


94/153



95/153



Patient/client-related Instruction

Physical therapists are responsible for patient/client-related instruction across all settings for all

patients/clients.



96/153



Procedural Interventions

The physical therapy procedures and techniques, whichinclude:

Therapeutic exercise

Functional training in self-care and home

management (including ADL and IADL)

Functional training in work (job/school/play),community, and leisure integration and

reintegration (including IADL, work hardening, and

work conditioning)

Manual therapy techniques



97/153




The physical therapy procedures and techniques, whichinclude:

Prescription, application, and, as appropriate,

fabrication of devices and equipment (assistive,

adaptive, orthotic, protective, supportive, and

prosthetic) Airway clearance techniques

Integumentary repair and protection techniques

Electrotherapeutic modalities

Physical agents and mechanical modalities



98/153




Physical therapists select interventions based on thecomplexity and severity of the clinical problems.

In determining the prognosis, the interventions to be

used, and the likelihood of an interventions success,

physical therapists must also consider the

differences between the highest level of function ofwhich the individual is capable and the highest level

of function that is likely to be habitual for that

individual.



99/153





Patients/clients are more likely to achieve the

anticipated goals and expected outcomes that are

determined with the physical therapist if they

perceive a need to function at the highest level oftheir abilityand if they were motivated to function

habitually at that level.



100/153





Thus understanding the difference between what a

person currently does and what a person potentially

could do is essential in making a prognosis and

identifying realistic, achievable goals and outcomes.



101/153





Physical therapists ultimately must abide by the

decisions of the patient/client regarding actions,

tasks, and activities that will be incorporated into a

daily routine and regarding what constitutes ameaningful level of function.


102/153



103/153




The physical therapists selection of proceduralinterventions should be based on:

A prognosis that is associated with improved or

maintained health status through risk reduction,

health, wellness, and fitness programs, or the

remediation of impairments, functional limitations, ordisabilities



104/153




The physical therapists selection of proceduralinterventions should be based on:

A plan of care designed to improve, enhance, and

maximize function through interventions of

appropriate intensity, frequency, and duration to

achieve anticipated goals and expected outcomesefficiently using available resources.



105/153




The physical therapist selects, applies, or modifies theseinterventions based on anticipated goals and expected

outcomes that have been developed with the

patient/client.



106/153




In conjunction with coordination, communication, anddocumentation and patient/client-related instruction,

three categories of procedural interventions form the core

of most physical therapy plans of care:

Therapeutic exercise

Functional training in self-care and homemanagement (including ADL and IADL)

Functional training in work (job/school/play),

community, and leisure integration and

reintegration (including IADL, work hardening, and

work conditioning)



107/153




The other categories of procedural interventions may beused when the examination, evaluation, diagnosis, and

prognosis indicate their necessity.



108/153




Factors that influence the complexity of both theexamination process and the selection of interventions

may include:

Chronicity or severity of current condition

Level of current impairment and probability of

prolonged impairment, functional limitation, ordisability

Living environment

Multisite or multisystem involvement


109/153



110/153




Through routine monitoring and reexamination, thephysical therapist determines the need for any alteration

in an intervention or in the plan of care.

The interventions used, including their frequency and

duration, are consistent with patient/client needs and

physiological and cognitive status, anticipated goals

and expected outcomes, and resource constraints.

The independent performance of the procedure or

technique by the patient/client (or significant other,

family, or caregiver) is encouraged following

instruction in safe and effective application.



111/153




Failing to intervene appropriately to prevent illness or tohabilitate or rehabilitate patients/clients with impairments,

functional limitations, and disabilities leads to greater

costs for both the person and society.

The APTAs Guide to PT Practice provides

administrators and policy makers with the information

they need to make decisions about the cost-

effectiveness of physical therapist intervention.

Treatment Planning


112/153

Treatment Planning

An effective treatment program beginswith a good initial plan.

The initial plan consists of the proposed

treatment goals or objectives, and thecorresponding interventions that will be used

to achieve each of the treatment goals.

Treatment Planning


113/153

Treatment Planning

Requirements of a Good Treatment Plan It addresses all the identified problems. It is

relevant.

There must be a specific goal and treatmentprocedure for each of the problems in the problem

list.

This is true even for problems that will be referred to

other team members.

Treatment Planning


114/153

Treatment Planning


relevant.

The plan should also set specific goals andtreatment procedures for potential problems.

All potential secondary problems that are likely to occur

in the patient, in his lifetime, must be enumerated in the

problem list and a corresponding treatment goal and

preventive measure must be included in the plan.

Treatment Planning


115/153

Treatment Planning


relevant.

Whenever possible, the treatment should reflectthe same kind of priority as that of the problem list.

This will lead to effective time management and will be

discussed further below.

Treatment Planning


116/153

Treatment Planning

Requirements of a Good Treatment Plan It is realistic.

No matter how impressive and complete a PT/OT

plan is, it will be of no value if it cannot beimplemented in full.

When designing the initial plan the therapist must make

sure everything written there can be implemented without

difficulty.

Treatment Planning


117/153

Treatment Planning


Some Guide Questions to Arrive at a Realistic

Plan: Can the short-term goals be achieved within the giventime frame?

Can the entire treatment program be completed within

the scheduled appointment of the patient?

Does the unit/facility have all the materials andequipments needed to implement the program and

evaluate the outcome?

Treatment Planning


118/153

Treatment Planning


Some Guide Questions to Arrive at a Realistic

Plan: Is the available manpower sufficient and competent indelivering the recommended management? If not, can

the therapist supervise and/or train staff to implement the

program effectively?

Can the patients cooperation be depended uponparticularly for the home program? Can the patient afford

to pay for the program?

Treatment Planning


119/153

Treatment Planning

Requirements of a Good Treatment Plan It is appropriate to the problem, as well as

appropriate to the patient/client and/or case.

This is self-explanatory. The treatment goal will work at the specific problem while

the intervention will accomplish the goal.

Treatment Planning


120/153

Treatment Planning



Aside from making a plan that is appropriate to theproblem, the plan should also be designed

according to the needs of the patient.

The holistic approach of rehabilitation makes each

treatment program unique.

The patient plays an active role and participates intreatment planning.

Treatment Planning


121/153

Treatment Planning



Aside from making a plan that is appropriate to theproblem, the plan should also be designed

according to the needs of the patient.

Therefore, unlike most medical or surgical treatment

programs the rehabilitation program cannot be packaged

as a single program/protocol and prescribed to all caseswith the same diagnosis.

Treatment Planning


122/153

Treatment Planning

Requirements of a Good Treatment Plan It is cost-effective.

Only a patient and his/her family are in a position

to decide whether they can afford to undergo

treatment or not.

A therapist should never make this decision for them;

neither should the cost of treatment deter a therapist

from planning the program best suited to the patient.

Treatment Planning


123/153

Treatment Planning


The responsibility of the therapist is to come up

with an appropriate and complete program that will

achieve the desired results within the shortest

possible time and at the least cost without

compromising the quality of the results.

This rule applies to all patients regardless of stature.

It is unethical to withhold a good treatment strategy froma patient who is assumed to be of low stature and to

over-charge or design complicated but unnecessary

procedures for patients assumed to be of high stature.

Treatment Planning


124/153

Treatment Planning


The ideal program must always be presented to

the patient and his/her family.

The advantage of such program and required duration

and cost should also be presented.

The patient and his/her family will decide, based on the

given information, if they can mange to complete the

program and if they can afford it.

Treatment Planning


125/153

ea e a g


The ideal program must always be presented to


If the patient/family verbalizes a problem with regard to

compliance and/or finances, the therapist must now

present alternative plans and explain the advantages and

disadvantages of these alternatives compared to the

ideal program.

An excellent and highly efficient therapist is always able

to come out with an effective program suited to the needs

of all patients.

Treatment Planning


126/153

g

Requirements of a Good Treatment Plan It leads to effective time management.

In actual practice, most clinics/facilities will have

only a limited number of therapists.

In fact, most clinics are managed only by one therapist.

Assistants, aides, and/or interns are available to help in

the implementation of the program but evaluation,

planning, and monitoring are responsibilities of the

therapist alone. The most difficult task of the therapist is in supervising

the staff and making sure that the prescribed treatment

plan is being carried out properly.

Treatment Planning


127/153

g




This job is made easier when the plan is written in such a

way that when the staff follows each step in the plan

he/she:

Will know exactly what to do.

Will give each treatment procedure in the correctsequence.

Will complete the program at the shortest possible

time and without error.

Treatment Planning


128/153

g




This job is made easier when the plan is written in such a

way that when the staff follows each step in the plan

he/she:

Can immediately implement alternatives in the event

that circumstances prevent him/her from carrying outthe original program.

Can identify indicators that will suggest that the

treatment is going well or not.

Immediately knows when he/she has to refer the

case to the therapist.

Treatment Planning


129/153

g


When each case is handled efficiently, more

patients can be accommodated and each patient is

assured of a safe, well-implemented, and

appropriate program.

Treatment Planning


130/153

g

Requirements of a Good Treatment Plan It is dynamic.

Common Observations in Clinics/Facilities

Regarding Patient Treatment:

There is a tendency in therapists in clinics/facilities to

convert evaluation, treatment, and monitoring procedures

into pre-designed fixed protocols.

There is also a tendency in therapists in clinics/facilities

to maintain a patient on the original treatment plan for theentire duration of the treatment or confine themselves to

the prescription until the scheduled

reexamination/reevaluation.

Treatment Planning


131/153

g


The therapist must never limit or confine his/her

evaluation and treatment plan to a fixed protocol or

maintain a patient on a fixed plan even if the

clinic/facility set-up strictly requires the prescription

of a physiatrist.

The therapist can always refer the case back to the

physiatrist with a report on the recent change in apatients status and recommend any change(s) in the

patients management.

Treatment Planning


132/153

g


A dynamic plan may change at any time.

It is not limited by norms but is very sound and can

always be justified.

A dynamic plan arouses the interest of the patient and

his/her family and solicits their cooperation unknowingly.

Dynamism may not be limited to the treatment plan

alone. Dynamism can also be applied to the treatment

approach.

Treatment Planning


133/153

g

Guidelines in Prescription Writing: It is usually best to tabulate the Initial Plan.

When the problem list is complete and prioritized,

tabulating the plan against each of the problems

will result in a complete and prioritized treatment

plan.

Always make and write a complete

prescription.

Treatment Planning


134/153

g

Guidelines in Prescription Writing: Whenever possible write the orders in the

desired sequence in which it should be

carried out. Even if the entire plan is tabulated, always do anenumerated prescription.

When requesting for evaluation procedures

and/or prescribing treatment proceduresspecify the desired technique in situations

where other approaches are also used.

Treatment Planning


135/153

g

Guidelines in Prescription Writing: Be as specific as possible when writing the

goals.

The therapist has to reevaluate the treatmentprogram regularly.

The basis for the effectiveness of the program will be the

outcome. It is easier to assess the program when the

desired outcome has been specified.

Treatment Planning


136/153

g

Guidelines in Prescription Writing:As much as possible include the time limit or

time frame in the prescription. However, be as

accurate as possible in your predictions. The time frame must have a sound basis.

Do not be too pessimistic in setting the time frame

either.

Treatment Planning


137/153

g

Guidelines in Prescription Writing:Always take into consideration the goals of


This is especially important under the followingcircumstances:

The program will require a change in lifestyle for the

patient and/or his/her family.

The cooperation of the patient and/or family is essential

for success. The family has very limited finances or has limited

insurance coverage.

Treatment Planning


138/153

g

Guidelines in Prescription Writing:Always take into consideration the goals of


This is especially important under the followingcircumstances:

The disability has been present for a long period and

patient suddenly decides to undergo rehabilitation and/or

there is a history of doctor-shopping.

Most of these patients have unrealistic goals. When evaluation of the patient shows that therapeutic

intervention can be of very little help to the patient.

Treatment Planning


139/153

Guidelines in Prescription Writing: Whenever possible focus and/or emphasize

on functional goals and outcomes.

To justify the need to undergo treatment incountries whether insurance companies pay for the

cost of treatment, there must be a significant

improvement in the function of the patient.

This usually includes the ability to perform ADL,

ambulate independently, and in some occasions theability to return to gainful employment.

Writing Plan Content in a SOAP

Format


140/153

Format

The Plan portion of the SOAP notecontains the plan for the patients

treatment.

One or more treatments exist to achieveeach of the STGs.


Format


141/153

Format

Information That Must Be Included UnderPlan:

Frequency per day or week that the patient

will be seen. The treatment that the patient will receive.

The amount of specificity may depend on the

setting.

If a discharge summary, where the patient isgoing and the number of times the patient

was seen in therapy.


Format


142/153

Format

Other Information Frequently IncludedUnder Plan:

The location of the treatment.

The treatment progression. Plans for further assessment or

reassessment.

Plans for discharge.


Format


143/153

Format


Patient and family education.

Any home program plans or what was taught to thepatient or the patients family.

A signed and dated copy must be attached to the

note, if possible.


Format


144/153

Format


Equipment needs and equipment

ordered/sold to the patient (if a dischargesummary).

Referral to other services; if there are plans to

consult with the patients physician regarding

further treatment or referral.


Format


145/153

Format

The Plan portion of the note describes theplan for the patients treatment (what the

patient will receive).

This differs from the situation of describing thetreatment and reaction to treatment in the

Objective portion of the note.

If treatment is addressed in the Objective portion of

the note, it may include specifics of what was donewith the patient that day and/or the patients

reaction to treatment.


Format


146/153

Format

Relationship to Short-Term Goals: Once the short-term goals are set, a

treatment plan is then set up to achieve each

of the short-term goals.

One intervention may achieve more than one goal.

In fact, it is advantageous and economically sound

to establish the treatment program to achieve the

goals most efficiently.

When setting up a treatment program, each short-

term goal, the patients allotted time for therapy,

the patients endurance level, and the patients

level of boredom must be considered.


Format


147/153

Format

Things to Consider When Recording theTreatment Plan:

Modalities:

Which modality? Where?

How long?

Intensity?

What position?


Format


148/153

Format


Ambulation:

Distance? Level of assistance?

Device(s)?

Time?

Weight-bearing status?

Type of gait pattern?


149/153


Format


150/153

Format


Exercise:

Home programs? Brief goal/rationale statement

Illustrations

Position

Directions (keep language simple and in patient terms)

Repetitions and times/day

Progression

Equipment

Precautions


151/153

Evaluation and Monitoring of the

Initial Plan


152/153

Initial Plan

Even the best of plans may not yield theexpected results.

In patients, this is usually due to an

unexpected change in the clinical course ofthe patient and to socioeconomic

circumstances that were not thoroughly

investigated.

Evaluation and Monitoring of the

Initial Plan


153/153

Initial Plan

To be able to detect such unexpectedcourses in a patient, the therapist should

already prepare a scheme that will

facilitate evaluation and monitoring. For beginners, this is done best through a

tabulation of the most important and relevant

indicators of successful treatment.

Documents

Assessment and Plan