What is Assessment?
“Assessments” (a.k.a. Evaluation per APTA – the Guide language) is perhaps the hardest thing to learn for a young clinician trainee. It is difficult because it is NOT what you see, but what you do not visualize directly, rather must use your thinking powers. These “thinking powers” must be trained, though it comes more naturally to some, than others. Most important however is that it can be learned, but only if you are willing to think.
Assessment follows after you have finished your physical examination, and after your review of the investigative workup (Laboratory results, and Imaging).
Assessment is NOT a repetition of facts that have already been extrapolated during the physical examination.
Let’s consider an explanation of what I mean. Let’s say, during physical examination of strength, you find the manual muscle test (MMT) number as 3+/5 globally, in a patient who was admitted with symptoms of diarrhea, falls, and confusion.
In this above case, most of the time it is easy to say that the patient is “weak”. Question is, did you need to be a rocket scientist to extrapolate that? If your documentation states MMT as 3+/5, does it take a doctoral degree to figure this out?
When you write “3+/5” it signifies that out of a normal value of 5, the patient has a strength of 3+. Just about any “reasonable” person can then perhaps figure out that it is less than normal. Which means, it is “weak”. That, therefore, is not professional “assessment”. So, what is entailed in a comprehensive assessment?
Components of Assessment:
Item |
Discussion |
| Summary | – a 1 – 2 sentence summary of the entire patient, with findings, and diagnosis, if known, up until the time. |
| Problem list & Etiology | – A list of individual problems, and their possible etiologies (this is the differential diagnosis of individual problems). You can list as many problems as you have found – Remember, the Problem List is discipline specific. You should not use problems that are not of your specialty. So, if a patient has diarrhea (from the example above), that should not be part of your problem list, but rather, ones that you have found during “YOUR” examination that should be considered here. |
| Remedy for above problem list | – Not all problems you found can be remedied by PT, even though it might be within scope of PT. For example, weakness is a scope of PT, but, not all weakness can be “fixed” by PT intervention. In this portion, you discuss which etiologies as discussed above are remediable by PT intervention? Does any of these problems require further investigative testing? For example, if a patient has weakness, does it need to be verified by EMG/NCV, or, maybe some other testing? Some testing cannot be done as inpatient in a hospital in most circumstances and you have to learn that. You can make recommendation for outpatient testing in the future. |
| Additional Speculation, or, open-ended discussion |
– When the etiology of some of your problems are not available, and your differential diagnosis is inconclusive, or, you have thoughts about the patient’s recovery that is not part of above, you should include it here. For example, let’s say that a patient has some reason not to be able to walk longer distances, and their life-span is expected to be reasonably long, and their primary mobility problem is the limitation to independent functioning, then you feel a powered wheel chair is optimal. You can explain your rationale in your discussion. |
Example:
Let’s revisit our example patient from above: “…a patient who was admitted with symptoms of diarrhea, falls, and confusion….” where strength examination reveals an MMT of 3+/5 globally. Extrapolating from information above:
Summary:
“…This is the case of a xx-year old Male(Female), with a past medical history of ……., who was admitted with 3-day history of diarrhea, falls & confusion. We were consulted for rehab needs associated with the falls, & mobility issues. (this is your summary where you outlined who/what issues related to this patient).
| Problem list: | Cause / Discussion | Will PT Help? |
Weakness |
There is widespread (you can say “global” if you want) symmetrical weakness – most likely multifactorial – certainly non-neurologic (if there were no neurological signs), more so due to electrolyte imbalance caused by diarrhea; |
It depends on the cause. If cause is neuroMSK - then yes. If not, then can you think of what, or who, can help resolve this? |
Impaired mobility |
Impaired (describe components of mobility) |
|
Reduced aerobic capacity |
Persistently impaired aerobic capacity as evidenced by: (use test that you used)... |
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