1. ASSESSMENT Related To Treatment

2. INTRODUCTION
The aim of assessment is to define the patient's problems accurately. It is based on both a subjective and an objective assessment of the patient.
Why Assessment
TO Identify Problems.
To form Realistic (STG & LTG ) Setting.
To develop an appropriate plan of treatment.
To assess its effectiveness regularly in relation to both the problems and goals. ( outcomes Measurements)
Progression.

3. Patient Management System
The system of patient management used is based on the problem oriented medical system (POMS), This system has three components:
• Problem oriented medical records (POMR)
• Audit
• Educational program.

4. Patient Management System)
Patient Management System
The POMS is now widely used as the method of recording the assessment, management and progress of a patient. It is divided into five sections, as:
Database.
Problem list.
Initial plan and goals,
Progress notes.
Discharge summary

5. Subjective Assessment Assess Outcome of TreatmentNO
YES
Chart Review
Subjective Assessment
Objective Assessment
Assess Outcome of Treatment
Is current goal met
Discharge
STG & LTG
Problem List
Treatment
Analysis
SCHEME
Treatment Plan
Any Further goal

6. DATA BASE Demographic Information
History of presenting condition or Illness (HOPC) or (HOPI)
Previous medical history (PMH)
Drug history (DH)
Family history (FH)
Social history (SH)
Patient examination
Test results

7. Subjective assessment
Subjective assessment is based on an interview with the patient.
It should generally start with open-ended questions
As the interview progresses, questioning may become more focused on those important features that need clarification

8. Objective Assessment
Objective assessment is based on examination of the patient, together with the use of tests such as spirometry, arterial blood gases and chest radiographs.
A good examination will provide an objective baseline for the future measurement of the patient's progress.
By developing a standard method of examination, the findings are quickly assimilated, and the Physiotherapist remains confident that nothing has been omitted.

9. Investigations Investigations Related to NeuroMuscular System
Cardiorespiratory Status
Musculoskeltal System
Psychosocial System

10. Analysis and Patient Goals
Analysis is the physiotherapist's professional opinion of the subjective and objective findings
It is general short, concise summary of patient + main problem (s).
Patient Goals :
What a patient want to achieve.
Use patients family’s words where possible.

11. PROBLEM LIST
The second part of the problem oriented medical record (POMR) is the problem list
The information in the database, together with the subjective and objective assessment are then analysed as a whole, and integrated with the physiotherapist's knowledge of disease processes.
It consists of a simple, functional and specific list of the patient's problems at that time, not always
listed in order of priority.
It consists of a simple, functional and specific list of the patient's problems at that time, not always listed in order of priority.

12. PROBLEM LIST
Each problem is numbered and dated at the time of assessment.
The problem list should not only include those problems that may improve with physiotherapy (e.g. breathlessness on exertion).
The problem list should not be a list of signs and symptoms, as this would provide the wrong emphasis for treatment.
Problems once resolved should be signed off and dated. Any subsequent problems are added and dated appropriately.

13. Short term & Long term goals
All goals, both short- and long-term, should state expected outcomes and time frames.
For each of the problems listed, long- and short-
term goals are formulated.
Why write goals?
To help plan treatment to meet the specific needs and problems of patient.
To priorize treatment and measure effectiveness.
Monitor cost effectiveness.
Communicate the goals of patient to other health care professionals.

14. Long term goals:
Long-term goals are generally directed at returning the patient to his maximum functional capacity.
LTG Correspond to the problem list that was generated after the assessment.
Specifically, goals may be simplified to functions that are important to the patient e.g. to be able to walk home from the shops carrying one bag of shopping.
When setting goals for an inpatient, consideration must be given to his discharge.
If the home situation includes two flights of stairs to the bedroom then the goal of exercise ability should reflect this.
If physiotherapy is to be continued at home after discharge, one of the goals must be to teach the patient or a relative how to perform the treatment effectively.

15. Long Term Goals (LTG)
These should be specific, measurable, achievable, realistic and timed (SMART).
Specified over longer time frame(e.g 2 wks to 2 mnths)
They should take into account the:
Audience that you are speaking to.
Behavior that u want to change.
Condition that the behavior will be elicited.
Degree to which the change will be made.
Also should:
Be stated in functional term
Be clear
Indicate a time span(which can change)

16. Short Term Goals Correspond to the long term goals.
They are the steps along the way to achieving the long term goals.
The time frames is shorter, for example each week.
In general these are small, simple activities that are more easily achieved
the short-term goals, should be reviewed regularly as some patients may improve faster than others.
If goals are not met within the agreed time frame, then revision is necessary.
The time frame may have been too short, the goal inappropriate, or other problems need attention before this goal can be met
Goals should be RUMBA
Realistic - Unambiguous - Measurable
Behavioral - Attainable

17. Treatment Plan
A treatment plan is then deevised for each of these goals.
This process must be performed, where possible, in consultation with the patient
The importance of involving the patient himself cannot be overstressed, as cooperation is fundamental to nearly all physiotherapy treatment.
The treatment plan includes the specifics of treatment, together with its frequency and equipment requirements.
Patient education must not be omitted from the treatment plan as it is an important component of physiotherapy.
Initial Treatment:
Treatment done on patient on 1st day of assessment. (Modalities, Positioning, Home program, walking aids, family teaching)

18. PROGRESS NOTES
These are written on a daily basis using the 'subjective, objective, analysis, plan' (SOAP) format
Subjective - what the patient, doctors or nurses report
Objective - any change in physical examination or test, e.g. auscultation, chest radiograph
Analysis - the physiotherapist's professional opinion of the subjective and objective findings.
Plan - including changes in treatment and any further action.

19. PROGRESS NOTES
Entries are made for each problem, signed and dated. If there have been no changes, nothing further needs to be written.
Progress notes may also include:
A Graph
Graphs are particularly useful in displaying the change in a parameter with time, for example an asthmatic's peak expiratory flow rates.
A Flow chart.
Flow chart displays are useful if multiple factors are changing over a period of time, as may occur in the intensive care patient
Outcomes.
The short- and long-term goals provide a basis for evaluating the effectiveness of treatment in relation to the various problems

20. PROGRESS NOTES
One of the best indicators of outcome is the change in objective findings after treatment
Although changes that occur immediately after a single treatment are related to physiotherapy intervention alone,
changes over longer periods of time reflect treatment by the entire health team.
Chest auscultation before and after a treatment may provide a simple indication of the effectiveness of that treatment.
the chest radiograph can demonstrate the effectiveness of physiotherapy treatment by showing diminution in the area of collapsed/consolidated lung.
On a long-term basis, changes in lung function or exercise tolerance provide the most valuable measures of treatment outcome.
The analysis of outcome is then compared
with that expected (i.e. the goals). If there are discrepancies between the actual and expected outcomes then the plan (P) documents the changes to the goals and/or treatment, as required.

21. DISCHARGE SUMMARY
Upon discharge or transfer elsewhere, a summary should be written of the patient's initial problems, treatment and outcomes.
Instruction for home programmes and any other relevant information should also be included.
Discharge summaries are helpful to other physiotherapists who may treat the patient in the future.
The summary should always contain adequate information for future audit and studies of patient care.

22. This process ensures high-quality patient care.
CONCLUSION
Accurate assessment should reveal the exact nature of the patient's problems and delineate those that physiotherapy can improve. Only then can the best treatment be chosen to met patient Subsequent reassessment is essential to ensure that treatment is specific, effective and efficient.
This process ensures high-quality patient care.

23. S.O.A.P. Notes General points to remember:
All notes to be very short and concise.
Avoid unnecessary words
Clear handwriting
If an error (mistake)is made, put 1 line through the words and initial e.g take (initial)
“S” (Subjective): (descriptive statement)
Patients or families comment/concerns. What patient said appropriate to condition/Dx/treatment.
(e.g How felt after Rx)
2. Unnecessary to write “pt states” (or only once). Comments by family/caregiver-should say e.g Daughter stated_______
3. Optional on interim notes.
4. Can use the patient’s exact words to show his/her strong feelings, emotions, or improper use of words, e.g “get out”.

24. “O” (Objective): (facts)
must be organised, easy to read and find.
Includes therapist’s Objective observations of patient.
Include Rx/Tx treatment. E.g Modalities, dose, time.
# of repetitions, type, or exercise, position of pt etc.
Pain caused/relived by --- (what done specifically with patient).
Specific data to be included e.g. Gait-type, distance, surface tested on.
Equipment needed.
Weight bearing status(FWB/PWB).
In interim notes- address areas included in last set of short-term goals.

25. “P” (Planning process)
“A” (Analysis):
Look at SUBJRCTIVE and OBJECTIVE notes and determine the problem.
List of problems. Remember to list the patient’s description of his most serious problem first.
In interim notes- only listed if a new problem/resolved problem or if referring to a problem.
“P” (Planning process)
Write the treatment to be used for the patient into both your assessment and your SOAP notes under P. e.g. what you plan to do for the patient.
Plane must include:
Frequency
The Rx patient will receive.
Other suggestion to add to the plan
Rx progression, plane for further assessment, plan for D/C, Pt and family education, equipment needs, referral to other service.

26. Discharge notes
(on the patient’s chart for the doctor or for other health care professional)
The Rx the patient received.
Total # of Rxs.
Education provided to patient and family
Handouts or equipment given out.
Your recommendations on continuing care or follow-up.

27. Assignment 1 Database Objective assessment Subjective assessment
Medical records
Subjective assessment
History of Present illness
Socail & family History
Medical/Surgicakl/Drug History
Breathlessness, cough, sputum, wheeze, chest pain
Duration, severity, pattern, associations
Functional ability,
Disease awareness
Associated Diseases
Objective assessment
General observation from end of bed
Chest observation, palpation, percussion, Auscultation
Sputum
Physiotherapy techniques, exercise capacity
Test results
Spirometry
Arterial blood gases
Chest radiographs

28. Analysis
Problem list
Long Term Goals
Short Term Goals
Treatment plan
Initial Treatment

29. THANKS