Assessment and Plan

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?
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 the
patients problems, including functional
limitations, impairments, and disabilities.
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?
I need to establish, together with my
patient, outcomes that correspond to
his/her functional limitations, impairments,
or disabilities.
I need to consider, together with my
patient, what can be achieved within a
short period of time (anticipated goals).
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 be
performed on him/her while considering
many things on both our sides (safety,
cost-effectiveness, etc.).
I need to treat the patient with the
methods/techniques/interventions that we
both have decided on.
I need to check if the
methods/techniques/interventions that I
used/applied on my patient have worked.
If they worked, then I have to check what I
can do further for my patient.
If not, then I have to consider, together with
my patient, other
methods/techniques/interventions that may
work on him her.
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
The Patient/Client
Assessment
Elements of Patient/Client
Management in Assessment
Documenting Assessment Content in
a SOAP Format
3 elements of patient/client management
are incorporated in formulating the
Assessment portion.
These are:
Evaluation
Diagnosis
Prognosis
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.
Evaluation
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
Evaluation
The evaluation reflects:
Chronicity or severity of the current problem
Possibility of multisite or multisystem involvement
Presence of preexisting systemic conditions or
diseases
Stability of the condition
Evaluation
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
Evaluation
Evaluation encompasses all sections in the
Assessment portion of a SOAP note but is
mainly the process in considering the
significant findings (Problem List).
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.
Diagnosis
The assigning of a diagnostic label through
the classification of a patient/client within a
specific practice pattern is a decision reached
as a result of a systematic process.
Diagnosis
This process includes integrating and
evaluating the data that are obtained during
the examination (history, systems review, and
tests and measures) to describe the
patient/client condition in terms that will guide
the physical therapist in determining the
prognosis, plan of care, and intervention
strategies.
Thus the diagnostic label indicates the
primary dysfunctions toward which the
physical therapist directs interventions.
Diagnosis
The diagnostic process enables the physical
therapist to verify the individual needs of each
patient/client to similar individuals who are
classified 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.
Diagnosis
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.
Diagnosis
As in all other cases, the physical therapist is
guided by patient/client responses to those
interventions and may determine that a
reexamination is in order and proceed
accordingly.
Diagnosis
The objective of the physical therapists
diagnostic process is the identification of
discrepancies that exist between the level of
function that is desired by the patient/client
and the capacity of the patient/client to
achieve that level.
Diagnosis
In carrying out the diagnostic process,
physical therapists may need to obtain
additional information (including diagnostic
labels) 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.
Diagnosis
If the diagnostic process reveals findings that
are outside the scope of the physical
therapists knowledge, experience, or
expertise, the physical therapist refers the
patient/client to an appropriate practitioner.
Diagnosis
Making a diagnosis requires the clinician to
collect and sort data into categories according
to a classification scheme relevant to the
clinician who is making the diagnosis.
These classification schemes should meet
certain criteria.
Diagnosis
Criteria for classification schemes:
Classification schemes must be consistent with the
boundaries placed on the profession by law (which
may 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.
Diagnosis
Criteria for classification schemes:
The label used to categorize a condition should
describe the problem in a way that directs the
selection of interventions toward those
interventions that are within the legal purview of
the health care professional who is making the
diagnosis.
Diagnosis
The preferred practice patterns in APTAs
Guide to Physical Therapist Practice describe
the management of patients who are grouped
by clusters of impairments that commonly
occur together, some of which are associated
with health conditions that impede optimal
function.
Diagnosis
Each pattern represents a diagnostic
classification.
The pattern title therefore reflects the
diagnosis or impairment classification
made by the physical therapist.
The diagnosis may or may not be associated
with a health condition for patients/clients who
are classified into that pattern.
Diagnosis
The physical therapist uses the classification
scheme of the preferred practice patterns to
complete a diagnostic process that begins
with the collection of data (examination),
proceeds through the organization and
interpretation of data (evaluation), and
culminates in the application of a label
(diagnosis).
Diagnosis
Diagnostic labels are placed in the
Impressions/Summary section of the
Assessment portion of a SOAP note.
Diagnosis
Physical Therapy Diagnostic Classifications:
Musculoskeletal
Primary prevention/risk reduction for skeletal
demineralization
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
Diagnosis
Musculoskeletal
performance, range of motion, and reflex integrity
associated with spinal disorders
Impaired joint mobility, muscle performance, and range
of motion associated with fracture
performance, and range of motion associated with joint
arthroplasty
performance, and range of motion associated with bony
or soft tissue surgery
Diagnosis
Musculoskeletal
Impaired motor function, muscle performance, range of
motion, gait, locomotion, and balance associated with
amputation
Diagnosis
Neuromuscular
Primary prevention/risk reduction for loss of balance and
falling
Impaired neuromotor development
Impaired motor function and sensory integrity associated
with nonprogressive disorders of the central nervous
system congenital origin or acquired in infancy or
childhood
system acquired in infancy or childhood
Diagnosis
Neuromuscular
system congenital 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
Diagnosis
Neuromuscular
Impaired motor function, peripheral nerve integrity, and
sensory 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
Diagnosis
Cardiovascular/Pulmonary
Primary prevention/risk reduction for
cardiovascular/pulmonary disorders
Impaired aerobic capacity/endurance associated with
deconditioning
Impaired ventilation, respiration/gas exchange and
aerobic capacity/endurance associated with airway
clearance dysfunction
Impaired aerobic capacity/endurance associated with
cardiovascular pump dysfunction or failure
Diagnosis
Cardiovascular/Pulmonary
Impaired ventilation and respiration/gas exchange
associated 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 respiratory
failure in the neonate
Impaired circulation and anthropometric dimensions
associated with lymphatic system disorders
Diagnosis
Integumentary
Primary prevention/risk reduction for integumentary
disorders
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
Prognosis (including Plan of Care)
Prognosis
The determination of the predicted optimal level of
improvement in function and the amount of time
needed to reach that level.
May also include a prediction of levels of
improvement that may be reached at various
intervals during the course of therapy.
Prognosis is documented in the Assessment part
of a SOAP note as the outcomes and goals (Long-
Term Goals/Expected Functional Outcomes and
Short-Term Goals).
Plan of Care
Consists of statements that specify the anticipated
goals and expected outcomes, predicted level of
optimal 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)
Plan of Care
The plan of care is the culmination of the
examination, diagnostic, and prognostic
processes.
It is established in collaboration with the
patient/client and is based on the data gathered
from the history, systems review, and tests and
measures and on the diagnosis determined by the
physical therapist.
Plan of Care
In designing the plan of care, the physical therapist
analyzes and integrates the clinical implications of
the severity, complexity, and acuity of the
pathology/pathophysiology (disease, disorder, or
condition), the impairments, the functional
limitations, and the disabilities to establish the
prognosis and prediction about the likelihood of
achieving the anticipated goals and expected
outcomes.
Plan of Care
The plan of care identifies anticipated goals and
expected outcomes, taking into consideration the
expectations 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.
Plan of Care
Anticipated goals and expected outcomes are the
intended results of patient/client management and
indicate 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.
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.
Plan of Care
The plan of care includes the anticipated discharge
plans.
For patients/clients who require multiple episodes of
care, periodic follow-up is needed over the life span to
ensure safety and effective adaptation following changes
in physical status, caregivers, environment, or task
demands.
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.
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
Problem List
Provides a list of the major problems as
written in the Subjective and Objective parts
of a SOAP note.
Problem List
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 for
a summary of the patients significant medical
problems.
Problem List
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 covered
by a long-term goal/expected functional outcome.
Problem List
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, jotting
down or highlighting findings that are not WNL and
that can be influenced or changed by physical
therapy intervention.
Medical or psychiatric problems do not belong in the
physical therapy problem list.
However, discussion as to how medical or psychiatric
problems affect the patients potential or actual
performance in physical therapy should be included in
the Impressions/Summary part of the Assessment
portion of the note.
Problem List
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 general
manner, since this list is a summary of the more specific
details included under S and O.
Outcomes
State the final product to be achieved by
physical therapy.
Once the problem list is established, the
patients long-term goals are set.
Outcomes
Reasons for writing goals:
To help the physical therapist plan treatment to
meet 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
Outcomes
The structure of a goal (ABCDs of goal
setting):
Audience
Behavior
Condition
Degree
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 family
member.
NEVER the physical therapist.
Goals are patient-oriented, not therapist oriented.
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.
Outcomes
setting):
Behavior
Always stated using action verbs.
Be or know are not acceptable.
Demonstrate, list, and state are acceptable.
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 the
behavior.
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.
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 will
be achieved. (Needs clinical experience to
determine)
Must be expressed in terms of function, when
possible. (Not required in some facilities but allows
other readers to understand the rationale behind the
goal)
Outcomes
setting):
Degree
Example:
Number of feet
Number of repetitions
Muscle grades
Degrees of ROM.
Outcomes
Criteria for revision of LTG:
The patients condition changes and will not allow
progression 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.
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 patient
interview (S portion) when setting LTG.
Short-Term Goals
STG are written as steps toward achieving LTG.
Outcomes
Expected functional outcomes are LTG.
In functional outcomes report (FOR) format, only
functional goals are stated.
The focus is on what the patient can and cannot do
due to a physical impairment, not the impairment.
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 (ABCDs
of goal setting).
Criteria for revision of STG:
Time period mentioned in a previous STG has
passed.
The patient has achieved the STG.
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.
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 justifying
decisions for goals and treatment plan.
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
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
The Treatment Plan
Management in Planning for
Intervention
Treatment Planning
Writing Plan Content in a SOAP
Format
Evaluation and Monitoring of the
Initial Plan
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
Management in Planning
Prognosis (specifically Plan of Care)
Discussed in the Assessment portion
Intervention
The purposeful interaction of the physical
therapist and the patient/client and, when
appropriate, with other individuals involved in
patient/client care, using various physical
therapy procedures and techniques to
produce changes in the condition that are
consistent with the diagnosis and prognosis.
Intervention
Decisions about interventions are contingent
on:
timely monitoring of patient/client response
progress made toward achieving the anticipated
goals and expected outcomes
Coordination, communication, and
documentation and patient/client-related
instruction are provided as part of intervention
for all patients/clients.
Intervention
The use of procedural interventions, however,
varies because those interventions are
selected, applied, or modified according to
examination and reexamination findings and
the anticipated goals and expected outcomes
for a particular patient/client in a specific
diagnostic group.
Intervention
Physical therapist intervention encourages
functional independence, emphasizes
patient/client-related instruction, and
promotes proactive, wellness-oriented
lifestyles.
Through appropriate education and instruction, the
patient/client is encouraged to develop habits that
will maintain or improve function, prevent
recurrence of problems, and promote health,
wellness, and fitness.
Intervention
Components
Coordination, Communication, and Documentation
Patient/client-related Instruction
Procedural Interventions
Intervention
Components
Administrative and supportive processes intended to
ensure that patients/clients receive appropriate,
comprehensive, efficient, and effective quality of care
from admission through discharge
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
Intervention
Components
Physical therapists are responsible for
coordination, communication, and documentation across
all settings for all patients/clients.
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
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
Intervention
Components
The process of informing, educating, or training
patients/clients families, significant others, and
caregivers intended to promote and optimize physical
therapy services.
Intervention
Components
Instruction may be related to:
Current condition
Specific impairments, functional limitations, or
disabilities
Plan of care
Need for enhanced performance
Transition to a different role or setting
Risk factors for developing a problem or dysfunction
Need for health, wellness, or fitness programs
Intervention
Components
Physical therapists are responsible for patient/client-
related instruction across all settings for all
patients/clients.
Intervention
Components
The physical therapy procedures and techniques, which
include:
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
Intervention
Components
The physical therapy procedures and techniques, which
include:
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
Intervention
Components
Physical therapists select interventions based on the
complexity 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 of
which the individual is capable and the highest level
of function that is likely to be habitual for that
individual.
Intervention
Components
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 of
their ability and if they were motivated to function
habitually at that level.
Intervention
Components
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.
Intervention
Components
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 a
meaningful level of function.
Intervention
Components
The physical therapists selection of procedural
interventions should be based on:
Examination findings (including those of the history,
systems review, and tests and measures), an
evaluation, and a diagnosis that supports physical
therapy intervention
Intervention
Components
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, or
disabilities
Intervention
Components
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 outcomes
efficiently using available resources.
Intervention
Components
The physical therapist selects, applies, or modifies these
interventions based on anticipated goals and expected
outcomes that have been developed with the
patient/client.
Intervention
Components
In conjunction with coordination, communication, and
documentation 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 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)
Intervention
Components
The other categories of procedural interventions may be
used when the examination, evaluation, diagnosis, and
prognosis indicate their necessity.
Intervention
Components
Factors that influence the complexity of both the
examination 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, or
disability
Living environment
Multisite or multisystem involvement
Intervention
Components
Factors that influence the complexity of both the
examination process and the selection of interventions
may include:
Overall physical function and health status
Potential discharge destinations
Preexisting systemic conditions or diseases
Social supports
Stability of the condition
Intervention
Components
Through routine monitoring and reexamination, the
physical 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.
Intervention
Components
Failing to intervene appropriately to prevent illness or to
habilitate 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
An effective treatment program begins
with a good initial plan.
The initial plan consists of the proposed
treatment goals or objectives, and the
corresponding interventions that will be used
to achieve each of the treatment goals.
Treatment Planning
Requirements of a Good Treatment Plan
It addresses all the identified problems. It is
relevant.
There must be a specific goal and treatment
procedure 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
relevant.
The plan should also set specific goals and
treatment 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
relevant.
Whenever possible, the treatment should reflect
the 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
It is realistic.
No matter how impressive and complete a PT/OT
plan is, it will be of no value if it cannot be
implemented in full.
When designing the initial plan the therapist must make
sure everything written there can be implemented without
difficulty.
Treatment Planning
It is realistic.
Some Guide Questions to Arrive at a Realistic
Plan:
Can the short-term goals be achieved within the given
time frame?
Can the entire treatment program be completed within
the scheduled appointment of the patient?
Does the unit/facility have all the materials and
equipments needed to implement the program and
evaluate the outcome?
Treatment Planning
It is realistic.
Some Guide Questions to Arrive at a Realistic
Plan:
Is the available manpower sufficient and competent in
delivering the recommended management? If not, can
the therapist supervise and/or train staff to implement the
program effectively?
Can the patients cooperation be depended upon
particularly for the home program? Can the patient afford
to pay for the program?
Treatment Planning
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
Aside from making a plan that is appropriate to the
problem, 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 in
treatment planning.
Treatment Planning
Aside from making a plan that is appropriate to the
problem, 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 cases
with the same diagnosis.
Treatment Planning
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
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 from
a 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
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
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
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
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 correct
sequence.
Will complete the program at the shortest possible
time and without error.
Treatment Planning
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 out
the 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
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
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 the
entire duration of the treatment or confine themselves to
the prescription until the scheduled
reexamination/reevaluation.
Treatment Planning
It is dynamic.
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 a
patients status and recommend any change(s) in the
patients management.
Treatment Planning
It is dynamic.
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
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
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 an
enumerated prescription.
When requesting for evaluation procedures
and/or prescribing treatment procedures
specify the desired technique in situations
where other approaches are also used.
Treatment Planning
Be as specific as possible when writing the
goals.
The therapist has to reevaluate the treatment
program 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
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
Always take into consideration the goals of
This is especially important under the following
circumstances:
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
Always take into consideration the goals of
This is especially important under the following
circumstances:
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
Whenever possible focus and/or emphasize
on functional goals and outcomes.
To justify the need to undergo treatment in
countries 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 the
ability to return to gainful employment.
Format
The Plan portion of the SOAP note
contains the plan for the patients
treatment.
One or more treatments exist to achieve
each of the STGs.
Format
Information That Must Be Included Under
Plan:
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 is
going and the number of times the patient
was seen in therapy.
Format
Other Information Frequently Included
Under Plan:
The location of the treatment.
The treatment progression.
Plans for further assessment or
reassessment.
Plans for discharge.
Format
Under Plan:
Patient and family education.
Any home program plans or what was taught to the
patient or the patients family.
A signed and dated copy must be attached to the
note, if possible.
Format
Under Plan:
Equipment needs and equipment
ordered/sold to the patient (if a discharge
summary).
Referral to other services; if there are plans to
consult with the patients physician regarding
further treatment or referral.
Format
The Plan portion of the note describes the
plan for the patients treatment (what the
patient will receive).
This differs from the situation of describing the
treatment 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 done
with the patient that day and/or the patients
reaction to treatment.
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
Things to Consider When Recording the
Treatment Plan:
Modalities:
Which modality?
Where?
How long?
Intensity?
What position?
Format
Treatment Plan:
Ambulation:
Distance?
Level of assistance?
Device(s)?
Time?
Weight-bearing status?
Type of gait pattern?
Format
Treatment Plan:
Exercise:
Extremity or trunk?
Types?
Repetitions?
Position?
Equipment used?
Modifications?
Amount of resistance given?
Format
Treatment Plan:
Exercise:
Home programs?
Brief goal/rationale statement
Illustrations
Position
Directions (keep language simple and in patient terms)
Repetitions and times/day
Progression
Equipment
Precautions
Initial Plan
Even the best of plans may not yield the
expected results.
In patients, this is usually due to an
unexpected change in the clinical course of
the patient and to socioeconomic
circumstances that were not thoroughly
investigated.
Initial Plan
To be able to detect such unexpected
courses 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.

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