Patient/Client Management Format: Writing Systems Review

Prepared By: Floriza P. de Leon, PTRP

Categorizing Information in the Systems Review

Involves basic Cardiovascular/Pulmonary information (HR, RR, Blood Pressure, Edema)
Ex: Cardiovascular/Pulmonary System: impaired. BP: 140/85. HR: 90 bpm. RR: 20 rpm. Edema: pitting edema noted bilat. Ankles

Involves basic information on the integumentary system (integumentary disruption, continuity of skin color, skin pliability, or texture)
Ex: Integumentary System: impaired. Wound noted (R) ant. Leg. Skin discolored around area of wound. Skin thin and fragile bilateral Les.

It involves the basic information about the musculoskeletal system (gross symmetry during standing, sitting, and activities, gross ROM and gross muscle strength; height and weight)
Ex: Musculoskeletal System: gross symmetry: impaired in LEs in standing. Gross ROM: unimpaired bilat. LEs. Gross Strength: impaired bilat. LEs, (R)>(L). Height: 5 ft, 6 in Weight: 140 lbs

Categorizing Information in the Systems Review

It involves neuromuscular system (gait, locomotion transfers and bed mobility, balance, motor function motor control, motor learning)
Ex: Neuromuscular System: gait unimpaired. Locomotion: transfers unimpaired. Balance: unimpaired. Motor functions: unimpaired.

It involves communication style or abilities (whether communication is age-appropriate)

Ex: Communication: age appropriate and unimpaired

Involves pt.s affect (emotional and behavioral responses)

Ex: Affect: emotional/behavioral responses unimpaired

Involves pt.s cognition (oriented to person, place and time or the pt.s consciousness)
Ex:Cognition: level of consciousness unimpaired. Orientation to person unimpaired; orientation to place and time impaired

Categorizing Information in the Systems Review

Involves learning barriers (vision, hearing, inability to read, inability to understand what is read, language barriers needs for an interpreter) Ex: Learning Barriers: hearing: Pt. understands best when able to see therapists lips along with the use of hearing aid Involves learning styles (how the patient or client best learns pictures, reading, listening, demonstrating, etc) Ex: Learning Styles: Pt. learns best when rationale for exercises is given before demonstration Involves patients education needs (disease process, safety, use of devices or equipments, ADLs, exercise program, recovery and healing process and other education needs noted) Ex: Education Needs: disease process, home exercise program, use of the back in ADLs

The Patient/Client Management Format: Documenting Tests and Measures

Test and Measures is the section in which the results of tests and measures performed and the therapists observations of the patient are recorded when test and measures are recorded, the therapist can compare them test and measures recorded in the past Effectiveness of therapeutic interventions can be evaluated using comparisons of tests and measures prior to and after the interventions are performed Items belongs in the Tests and Measures if it is the result of a test performed by the therapist or an observation made by the therapist

Categorizing Items into Tests and Measures

Information should be organized , easy to read, and easy to find Headings or categories can be:
Ambulation Transfers Balance Range of motion (ROM) Strength Sensation Ambulation ADLs IADLs UEs LEs trunk

Or can be:

Example
Test & Measures: UEs: AROM: WNL except for 80 (R) shoulder flexion and 90 (R) elbow flexion. STRENGTH: 4-/5 throughout (R) shoulder musculature, 4+/5 biceps, 4/5 triceps, 3/5 musculature controlling the wrist and fingers. SENSATION: intact throughout Can use table format to get the information across in the most complete manner Can used standardized table used by the facility

Common Mistakes in Recording Data from Tests and Measures

Failure to state the affected body part Failure to state measurable information Failure to state the type of whatever it is that is being measured or observed