6 Chapter 06: CREATING SECTION ENTRIES

Before we create an entry, let’s look at some examples of simple Subjective entries.

Your entry might be very simple:

• “Patient in bright spirits and without c/o any pain; eager to participate in PT treatment.”

Or perhaps you want to be more succinct.

• “Patient offers that they ‘feel fine’ today; no c/o pain.

Or perhaps you had given this patient an exercise to do back in their room.  You might ask them if they did their exercise last night and if so, how did it go.  You could then include this information to your note – as it is relevant to their condition and treatment.

• “Patient in bright spirits today; no c/o pain. Offers that they completed the HEP two times last night without difficulty”.

REFLECTION POINT:  Remember to use the guidelines for medical documentation.  Some examples of this include:

• Patient reports pain at side of left hip. SOAP version: Patient c/o  left lateral hip pain.
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• Maybe your patient told you that since the last treatment, he is able to do more stuff around the house and it doesn’t hurt so much when he does. Rather than enter that long sentence in quotes you could change it: SOAP version: Patient reports increased functional mobility at home with decreased pain following last treatment.

The Subjective:

Probably the most common report a patient will give us is about their level of pain.  In situations where we are treating patient primarily for their pain or pain is the primary limiting factor in their recovery, we need to obtain as much relevant information about the pain as we can.

EXAMPLE:  Development of an entry for ‘Pain’

• Let’s say we want to report the patient’s level of pain.  We could ask the patient what their pain level is from 0 – 10.  For our example, the patient answers with their present level of pain which is a 7/10. Our entry at that point would be:
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  “Patient reports 7/10 pain”.
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  Well, that’s a start. If, however, you want to have a thorough, descriptive and informative note, you will want there to be more detail.
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• Certainly, we will also need to describe the location of the pain.
  • “Patient reports right knee pain of 7/10”.   Maybe more detail is needed: “Patient reports 7/10 pain at the medial aspect of the right knee”.
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• We’re off to a good start, but there are a few things missing yet.

• Maybe one of the items you would add is the type of pain.  This can be very helpful as it may help identify the structures involved in the condition as well as the severity of the situation.  Our entry might now be:
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  •  “Patient reports a dull ache at the medial aspect of the right knee of 7/10”.
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• Better, but did maybe you have already considered that pain is rarely constant, it varies. So it is helpful to get a pain ‘range’ from our patient:

• • “Patient reports a dull ache at the medial aspect of the right knee of 3-7/10”.  As the therapist, what question would you want to now ask the patient?
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• Maybe you decided to ask the patient: “Can you tell me what causes your pain to vary; what cause it to increase and decrease?”  The answer to this question is very helpful in understanding what is causing the pain and how to best treat it. Let’s include that type of information to our entry:
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  • “Patient reports a dull ache at the medial aspect of the right knee of 3-7/10; increases when ambulating up hills; decreases when elevated or sitting.”
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• While this is a descriptive and informative entry and maybe sufficient for many cases, we may want to link information about pain to the patient’s progress in PT.  In those cases, you might ask questions to determine how the pain limits the patient at home or work, how the pain responds to PT treatment immediately and/or in the hours after treatment or anything else that you think is relevant for that patient.  For a patient that works between two floors of an office building, we might have an entry that reads:
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  • “Patient reports an achy right knee pain of 3-7/10; increases most when ambulating up and down stairs at work; decreases when elevated, sitting or in the hours following PT treatment”.

Hopefully you can now see how such an entry would help explain why we used interventions to decrease knee pain (modalities, massage, home pain reduction techniques) and increase patient’s ability to ambulate on stairs without pain (therapeutic exercises, stair training activities, patient education, etc.).  In other words, what is entered in the Subjective section is relevant to (connected to) what is done with the patient in the Objective section, analyzed in the Assessment section and used to determine our Plan.

This is just an example of how we can develop a given entry to make it clear and thorough. How we do so, what information we include about a given topic, is influenced by the ‘particulars’ of the patient.  This will make sense as you move forward with your various PT courses this year and as you complete your clinical experiences.  For now, it is important to just understand that we need to be thoughtful about what we enter and how we enter it.

The Objective

If you remember, the examples of Objective section entries above illustrated that this section of the note is where we enter the ‘facts’ of the treatment: Our interventions.

Sometimes it is helpful to think of the ‘facts’ as categories. Below are categories that may be included in the Objective section of a note. Which ones you select depends on the patient’s diagnosis and situation.

You would not, for example, have an entry for gait or transfers if you are working in an outpatient clinic with a fully independent individual with a diagnosis of lateral epicondylitis. That will make more sense as you practice documentation this semester and make even more sense during your clinical affiliations.

Examples of “Topic Headings” included in the Objective section:

O:      Gait:

Transfers:

Bed Mobility:

Ther exercise:

Vital Signs:

Balance training:

Endurance:

ROM/ Goniometry:  Entered as one or more of the following: AROM, PROM or perhaps AAROM depending on the situation.

Strength (MMT results):

Manual Treatment interventions:

Modalities:

Wound care:

HEP Instruction:

Patient Training: (Use of assistive device, use of adaptive equipment, diaphragmatic breathing, caregiver education…)

For each “TOPIC HEADING”, we need to include relevant information:
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O:  Gait:     At the minimum, we need to enter:

                   Weight bearing status, level of assistance, the distance ambulated, the device used, the deviations present.

Of course, we will use other metrics as appropriate.  For example, we might offer more information about ‘why’ we are   providing assistance: Due to balance impairment or weakness or fear…

Examples of Gait entries:

Gait Training:    WBAT RLE. 50’ x 1; 100′ x 1: RW, CTG d/t right knee pain. Decreased left step length d/t antalgic pattern on right. Verbal cues required to facilitate  weight shift onto RLE.
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Gait training:   FWB. 80’ x 2 c CTG /S for safety. Patient c 2 episodes of LOB to the left.   Gait speed: 1’15” x 1.  1’30” x 1.

Transfer Entries:

Many of the same metrics will apply for transfers.

Transfers:    Weight bearing status, type of transfer, devices (if any) used,direction of transfer if applicable, deviations,  amount of assistance given (manual, verbal or both) & why.  Of course, their may be other metrics you may choose to add as well.

Some simple examples:

O:  Transfer Training:  PWB’g RLE. Stand pivot transfer: w/c to mat table. Min A of one with verbal cues regarding weight bearing.
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O: Transfer Training: WBAT LLE.  CTG supine to/from sit; Sit to stand with S and RW; no loss of balance or report of dizziness.

Therapeutic exercise:

Note any precautions: Weight bearing, cardiac, lifting, spinal, ROM, etc.

Include for each exercise:   Reps, Sets, Resistance, Position of Patient, Type and amount of assistance or instruction required.  You will also note any deviations or compensations you observe — and how you addressed those deviations.

Examples of Therapeutic Exercise:

Ther Ex:  Patient completed SLR’g in supine with 2 pillows to elevate RLE; 3 x 12 with vcs as well as ctg 50% of the time to achieve full knee extension. Verbal cues also provided to facilitate correct breathing.
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Ther Ex:  Seated rowing with blue TB. 3 x 8 with manual and verbal cues for correct technique and posture. Patient assumes forward head posture when uncued and then reports discomfort right shoulder.  With upright posture, no report of pain.

The Assessment

So, if the Subjective part of a note explains the how the patient feels they are progressing or not; how their current impairments are impacting their life and the Objective part of the note explains ‘what’ you are doing to address the patient’s subjective report. The   Assessment explains what the patient needs to achieve to reach their goals, why you are doing what you are doing (the rationale for your PT interventions) as well as why the patient is or isn’t progressing. 

Said in a different form, in the Assessment you will:

• Document the patient’s progress – or lack of progress
• Describe how the patient’s deficits and impairments impact their progress.
• Explain why the patient may be experiencing difficulty in a given area
• Explain why you are providing your chosen interventions (your treatment rationale).
• Offer your analysis of ‘what’ may help the patient improve.

 It might be helpful to think of the Assessment like this:

Your friend asks, “What was it about?”     You answer with the plot. 

This is like the Objective part of a note as it is just the facts:

“Lonely scientist discovers cure for old age. Sells it on the black-market only to regret it. He steals it back with the help of a superhero – they get married.”

However, if your friend asks, what did you ‘think about’ the movie?    You offer your analysis.

This is like the Assessment part of a note:

“It was too long because it lacked concise and relevant dialogue. Too much time spent on issues unrelated to the plot or character development”.  The director needs further training with managing dialogue and plot development”.

Now let’s look at the opposite.  Let’s check out some effective verses ineffective assessments.

Examples of EFFECTIVE verses INEFFECTIVE Assessment statements.

A: Tolerated treatment well  —    Ineffective and definitely not acceptable.
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A:  Patient c poor RLE quad control during stance phase of gait.  This contributes to R knee buckling in gait and during functional activities.

A:   Patient has pain. Needs assistance.     Vague, not descriptive or helpful. Ineffective and not acceptable.
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A:    Patient’s right knee pain causing intermittent buckling of RLE during WB’g. Manual assistance required for safety during gait and transfers.

A: Patient’s knee hurts so he doesn’t exercise too well.  Vague, inappropriate terminology: ineffective and not acceptable.
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A:   Patient with increased knee pain in weight bearing which limits the amount of standing exercises he can complete before compensatory patterns emerge.

A: Patient unsteady with SPC.   Lacks clarity: Ineffective and not acceptable.
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A: Patient would benefit from use of rolling walker (3” fixed wheels with glide caps) for home use given impaired balance with use of SPC.  Patient does demonstrate safe use of rolling walker and understanding of its management in clinic.

A: Patient just got to go to a nursing home.      Nope, nope, nope.

A: Patient appears to require skilled nursing facility post-d/c due to impaired ambulation, impaired balance and impaired safety awareness; patient not yet ready for safe discharge home.

The Plan

The Plan explains the ‘what’ and ‘when’ of the next treatment. As a review, some examples:

P:   Will continue with the present PT POC 3x/wk x 2 wks.

P:  Patient to see MD tomorrow; PT of record to reassess patient next visit.

P:  Continue PT POC towards current goals.

P:  As per assessment, PT of record to request addition of thermal modalities to PT POC.  Will integrate these interventions into PT POC once MD order reviewed. Continue as per current POC.