Chapter 06: CREATING SECTION ENTRIES
Subjective Entries
Before we create an entry, let’s look at some examples of simple Subjective entries.
You are working at in a nursing rehab facility. Your first patient of the day arrives in a wheelchair. When you ask how they are doing, the patient explains that they feel fine today and they did not have any pain after their last PT treatment. They are looking forward to today’s therapy.
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.
- 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.
DOC Ex 14: Practice Time: Please create Subjective entries out of the following
- Your patient informs you that she is now using her right arm during cooking and cleaning again and when she does so, it doesn’t hurt that much.
- You are working in a nursing rehab facility. Your patient is being seen in PT because they recently had pneumonia and became very deconditioned. They arrive in the gym and you ask how they are doing. The patient tells you that they are really tired this morning because they had trouble sleeping last night. They do not have any pain.
- Let’s say instead they reported that they are exhausted today because of too much cotton-picking PT yesterday. They do not have any pain. What might you enter?
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.
DOC Ex 15: The trouble with pain…
Documenting pain is tricky: It is such a subjective entity and yet, it can be so very helpful in identifying a patient’s problem. Getting the ‘right’ or the ‘best’ information about the patient’s pain is a skill.
It may be helpful to first think of a time that pain brought you to a medical professional, parent or caregiver. What ‘things’ did you want to tell them about the pain? List a few of these items:
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:
- “Patient reports 7/10 pain”.
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.
- 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”.
- We’re off to a good start, but there are a few things missing yet.
DOC Ex 16: …is there anything else you would like me to know?
This phrase may be helpful to you in the clinic. Often, once a patient tells you about their pain as a stream of consciousness, they often land at the main issue. Offering a simple, ‘Is there anything else?’ gives them the chance to express that ‘bottom line’.
So…regarding our situation above, can you think of anything else you would want to know? Think back to what you added when you were the patient. What questions might you now ask?
- 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:
- “Patient reports a dull ache at the medial aspect of the right knee of 7/10”.
- “Patient reports a dull ache at the medial aspect of the right knee of 7/10”.
- 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?
- “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?
- 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:
- “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.”
- “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.”
- 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:
- “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.
DOC Ex 17: Once Again…
Developing a Subjective Entry.
As you learn more about the pathophysiology of diseases, injuries and illnesses, you will know ‘what’ questions to ask given the diagnosis or diagnoses of your patient. The answers you receive will allow you to create an entry that will help reveal more about the nature of the patient’s condition, their progress in PT…or why PT is not yet helping.
Time for you to play Sherlock Holmes once more.
What questions might you ask the patient below to learn more about their fatigue?
You are working in a nursing rehab facility. Your patient is being seen in PT because they recently had pneumonia and became very deconditioned. They arrive in the gym and you ask how they are doing. The patient tells you that they are exhausted today because of that cotton-picking PT yesterday. They do not have any pain.
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:
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…
DOC Ex 18: Test your knowledge
- Please list five weight bearing statuses.
- Please list three gait patterns.
- Which is the gait pattern we use when the patient is not permitted to bear any weight on an extremity?
- If your patient has a RTKR, on which side will you be guarding during your gait training activities?
- Why?
- You are going to teach curb training to this patient with a RTKR:
- Which LE goes up the curb first?
- Where do you stand as the patient goes up the curb: On right or left side? In front or behind?
- Where do you stand as the patient descends the curb: On right or left side? In front or behind?
- What are you holding as the patient performs this skill….your breath is not the correct answer:)
- If this RTKR patient has pain during the weight bearing phase of gait, they will limit the amount of time they spend on which LE: Right or left?
- This response to pain will result in a particular deviation that you will see often in the clinic or hospital setting. What is the name of this deviation?
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.
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.
DOC Ex 19: Your turn to write a gait entry.
Please translate this narrative of a gait activity into an entry for the medical record.
The patient ambulated 50′ with a rolling walker twice. The therapist provided assistance (instructions and manual contact) while the patient completed their training. The patient’s right knee hurt, so they were not putting all of their weight on that leg when they walked causing a limping type of gait pattern. The patient is allowed to put as much weight on the right leg as they feel they can manage in terms or discomfort or strength.
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.
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.
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.
DOC Ex 20: Street-speak to Medical Speak. Please create entries for each of the following narratives.
- During your treatment today, your patient completed their ambulation activities with you three times. Each time they walked 30’ with a rolling walker. They did require you’re a little bit of your assistance as they walked because they were tired and unsteady.
- During treatment today, your patient practiced getting up and down from a wheelchair five times as well as going from the wheelchair to the mat table five times. They needed up to 25% assistance from you to complete these activities.
- During treatment today, your patient completed straight leg raises (SLR). They did each set of the exercise 12 repetitions. You had them on a mat table and used two pillows under their head because of their COPD.
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”.
Look at the Assessment example below. Can you see how a barrier to progress is identified, its impact on safety/function noted and an explanation of a treatment rationale offered?
Assessment: Impaired right ankle DF limits effective heel strike during initial contact. Steppage gait pattern results causing increased right hip flexion and this increases patient’s right hip pain. Continued ROM and strengthening activities yet required to eliminate gait deviations.
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.
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.
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.
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.
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.
DOC Ex 21: Assessment Activity. Please translate these ineffective assessment entries into effective assessment entries.
- Patient not ready to go home because they got up with a little bit of help.
Becomes: - Patient still needs to have someone hold them when they walk.
Becomes: - Therapist had to remind patient to use armrests when the patient sat down.
Becomes: - Patient needed cold pack after exercise because she had more pain in her right knee then she did before the treatment of exercises began today.
Becomes:
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.
DOC Ex 22: …and your plans..
Your patient is progressing nicely with their present treatment plan: They are seen three times each week. You do not see any need to change any of their treatments or their goals because of the patient’s steady progress and because the goals are still relevant and appropriate. How might you enter a plan?
DOC Ex 23: Quick Review
- The information included on a flow sheet goes into which section of the note?
- What metrics are included for a GAIT entry?
- What metrics are included for a TRANSFER entry?
- What do you call: “Tolerated treatment well” ?
- What is the term for intentionally entering an inaccurate metric to a medical document?
- You have just measured your patient’s elbow motion as they completed their best effort at flexion and extension of that joint. Where do you document this finding — and how do you enter it?