PROBLEM-ORIENTED MEDICAL RECORD

I. IDENTIFYING DATA
Name:
Address:
Age:
Sex:
Status:
Handedness:
Referring Physician:
Physiatrist:
Date of Referral:
Diagnosis:
II. SUBJECTIVE DATA
A. PATIENT HISTORY
It is obtained via interview of the patient. If communication disorders and cognitive deficits are
encountered during the rehabilitation evaluation, additional and collaborative information must be
obtained from significant others accompanying the patient. The spouse and family members are valuable
resources. The physician may also find it necessary to interview other caregivers, such as paid
attendants, the public health nurse, and the home health agency aide.
a.1. CHIEF COMPLAINT
In assessing the chief complaint, the intent is to document the patients primary concern in his or her
own words.
The complaint is often impairment in the form of a symptom that implies a certain disease or group of
disease.
Example:
The complaint of Chest pain when walking up a flight of stairs suggests cardiac
disease.
Of equal importance is recognition that the chief complaint, when lost of function is
expressed, also may be the first implication of a disability or handicap.
Example:
The complaint of a farmer that I can no longer climb up onto my tractor may suggest
neuromuscular or orthopedic disease and handicap by virtue of the inability to
accomplish vocational expectations.
The homemakers report that My balance has been getting worse and Ive fallen several
times may be related to disease involving the vestibular system and to the disability
created by unsafe ambulation.

a. 2. HISTORY OF PRESENT ILLNESS

It is obtained when the patient tells the story of the medical predicament.
These are the thing that should be observed in getting the history of present illness:
1. Let the patient relate the story regarding the condition
2. The patient should be asked to define the specific words he/she uses
3. Ask questions that are related to, and guide the patient regarding her/his present condition
4. Let the patient describe fully the symptoms and their consequences
5. A complete list of current medications should be obtained
There will more than one complaint elicited during interview. The character of each complaint should be
analyzed in an orderly fashion:
1. Date of onset
2. Character and severity
3. Location and extension
4. Time relationships
5. Associated complaints
6. Aggravating and alleviating factors
7. Previous treatment and effects
8. Progress, noting remission and exacerbation
a.3. FUNCTIONAL HISTORY
The rehabilitation evaluation of chronic disease often shows lost of function. Through the functional
history the examiner must characterize the disabilities that have resulted from disease and identify
remaining capabilities. The examiner must know not only the functional status associated with the
present illness but also the level of function at one or more times before the present illness.
Communication
A major component of rehabilitation is education; thus, communication is critical. The interviewer must
assess the patients communication options.
1. Listening
2. Reading
3. Speaking
4. Writing
Eating
It should be evaluated to prevent further consequences such as malnutrition, aspiration, and depression.
Grooming
The inability to make oneself attractive and presentable and to others can have injurious effects on ones
body image and self-esteem, social sphere, and vocational options.
Bathing
The ability to maintain cleanliness also has far-reaching psychosocial implications. In addition, deficits
in cleaning can result in skin ulceration and maceration, skin and systemic infection, and the spread of
disease to others.
Toileting
Ineffective bowel or bladder control has an adverse impact on self-esteem, body image, and sexuality
and often prevents the sufferer from employment and social relationships.
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Dressing
Dependency in dressing obviously results in a severe limitation to personal independence and should be
investigated thoroughly during rehabilitation review.
Bed Activities
The most basic stage of functional mobility is independence in bed activities. If the person cannot turn
from side to side to redistribute pressure and periodically expose skin to air, he is high risk to develop
pressure sores and skin maceration from heat and occlusion.
Transfers
The second stage of functional mobility is independence in transfers.
Ambulation
Wheelchair mobility
Ambulation
Operation of motor vehicle
a.4. PAST MEDICAL HISTORY
The past medical history is a record of a patients significant illness, trauma, and health maintenance
during his/her life. The effects of certain past conditions will continue to affect the present level of
function.
1. Neurologic Disorders
2. Cardiopulmonary Disorders
3. Musculoskeletal Disorders
a.5. REVIEW OF SYSTEMS
The systems are reviewed to screen for clues to disease not otherwise identified in the history of present
illness and the past medical history. A thorough review should always be completed. Many diseases
have potential for adverse effects on rehabilitation outcome.
1. Constitutional Symptoms
2. Head and Neck Symptoms
3. Respiratory Symptoms
4. Cardiovascular Symptoms
5. Gastrointestinal Symptoms
6. Genitourinary Symptoms
7. Neurologic Symptoms
8. Musculoskeletal Symptoms
a.6. PATIENT PROFILE
The patients profile provides the interviewer with information about the patients present and past
psychological state, social milieu, and vocation background.
a.6.1. PERSONAL HISTORY
Psychological and Psychiatric History
The patient should be screened for past or current anxiety, depression and other mood changes,
sleep disturbances, delusion, hallucination, obsessive and phobic ideas, and past minor and major
psychiatric illnesses.
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Life-Style
Leisure activities can promote both physical and emotional health. The patients leisure habits
should be reviewed to identify special rehabilitation measures that might return independence in
these activities.
Diet
Inadequate nutrition may inhibit rehabilitation efforts. The patients ability to prepare meals and
snacks, usual dietary habits, and special diets should be determined.
Alcohol and Drugs
Patients with cognitive, perceptual, and motor deficits can further impaired to a dangerous
degree through substance abuse.
a.6.2. SOCIAL HISTORY
Family
Catastrophic illness in the family members
Patients marriage history and status
Number of family members
Willingness of the family members to assist
Home
Home design should be reviewed for architectural barriers.
Distance between the home and the rehabilitation center
Accessibility of the different parts of the house (kitchen, bath, bedroom, living room)
a.6.3. VOCATIONAL HISTORY
Education and Training
The educational level achieved by the patient may suggest intellectual skills.
The educational background will dictate future educational and training needs.
The years of education completed by the patient (high school, undergraduate, graduate) and the
patients performance reviewed.
Work History
An understanding of the patients work experience can also determine whether further education
and training will be necessary. In addition, it provides an idea of the patients motivation,
reliability, and self-discipline.
Finances
This refers to the patients income, investments, and insurance resources, disability
classifications, and debts.
a.6.4. FAMILY HISTORY
It is used to identify hereditary disease within the family and to assess the health of people within
the patients home support system.

III. OBJECTIVE DATA

A. PHYSICAL EXAMINATION
Of necessity, it is a well-practiced art. Through perceptions gleaned from observation, palpation,
percussion, and auscultation the examiner seeks physical findings to support and formulate the diagnosis
further and to screen for other conditions not suggested by history.
After investigating the physical findings that help to establish the medical diagnosis, the examiner still
has two principal tasks:
1. To scrutinize the patient for physical findings to define the disabilities and handicaps that
emanate from the disease.
2. To identify remaining physical, psychological, and intellectual strengths to serve as the base
from which to re-establish functional independence.
a.1. VITAL SIGNS and GENERAL APPEARANCE
Blood pressure
Pulse
Temperature
Respiratory rate
Weight
a.2. INTEGUMENTARY AND LYMPHATICS
Pressure ulcer
Maceration
Skin infections
Skin breakdown
Erythema
Hair loss
Edema
Pigmentation
a.3. HEAD, EYES, EARS, NOSE THROAT
Trauma
Craniosacral abnormalities
Lid closure
Corneal ulceration
Conjunctivitis
Visual disturbances
Hearing loss
Tenderness
Swelling
Teeth and gums problem
a.4. CHEST
Rate, amplitude and rhythm of breathing
Cough
Hiccup
Labored breathing
Accessory muscle activity
Chest wall deformities
a.5. HEART AND PERIPHERAL VASCULAR SYSTEM
Arhythmias
Valvular disease
Congenital anomalies
Skin color
Dystrophic skin
Deep vein thrombosis
Raynauds phenomenon
a.6. GENITOURINARY SYSTEM AND RECTUM
Incontinence
Ulceration
Bulbocavernosus reflex
Sexual function

a.7. MUSCULOSKELETAL SYSTEM

Inspection
Scoliosis
Joint deformities
Leg-length discrepancy
Mass
Defect
Atrophy
Rupture
Palpation
Tenderness
Edema

Abnormal kyphosis and lordosis

Amputation
Soft tissue swelling
Scar
Muscle fasciculation
Hypertrophy

Consistency
Mass

Range of Motion Assessment

Reasons in getting human range of motion:
1. Initial evaluation
2. Evaluation of treatment procedure
3. Feedback to a patient
4. Assessment of work capacity
5. Research studies
Considerable variation exists among people when ROM measurements are compared. Factors such as
age, gender, conditioning, obesity, and genetics can influence the normal ROM.
Joint Stability Assessment
Joint stability is the capacity of the structural elements of a joint to resist forces of inappropriate vector.
It is determined by the degree of bony congruity, cartilaginous and capsular integrity, ligament and
muscle strength, and the forces required of the joint.
Manual Muscle Testing
Manual muscle testing provides an important means of assessing strength but also can be viewed as a
means of assessing weakness. The examiner needs to keep in mind many factors that can affect the
effort that a patient is willing to put into the testing. Such factors are age, gender, pain, fatigue, low
motivation, fear, misunderstanding of the test, and the presence of lower or upper motor neuron disease.
B. NEUROLOGIC EXAMINATION
b.1. MENTAL STATUS
Level of Consciousness
Determine the patients level of consciousness
Drowsy
Lethargic
Stuporous
Glasgow Coma Scale
Cognitive Evaluation
Orientation
Recall
Calculation
Judgement

Attention
General Fund of Information
Similarities
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b.2. SPEECH AND LANGUAGE FUNCTION

The patient should be evaluated for the presence or extent of aphasia, apraxia, and dysarthria, and
residual communicative skills should be identified.
Listening
Reading
Speaking
Writing
b.3. CRANIAL NERVES
Cranial nerve testing
b.4. REFLEXES
Muscle stretch reflexes
Superficial reflexes
Pathological reflexes
b.5. CENTRAL MOTOR INTEGRATION
Muscle Tone
Coordination
Alternate Motion Rate
Involuntary Movements
Apraxia
b.6. SENSATION
Superficial Sensation
Light touch
Superficial pain
Temperature
Deep Sensation
Joint position sense
Deep pain
Vibration
Cortical Sensation
Two-point discrimination
Graphesthesia
Stereognosis
Double simultaneous stimulation
b.7. PERCEPTION
Agnosia
Right-left Disorientation
C. FUNCTIONAL EXAMINATION
Eating
Bathing
Dressing
Transfers
Ambulation

Grooming
Toileting
Bed activities
Wheelchair mobility
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D. POSTURAL EXAMINATION

IV. ASSESSMENT
PROBLEM LIST:
The problem list includes the areas that were not within normal limits, when the subjective interview and
objective testing were performed. It is usually written in a list format.
1. Prerequisite step: Write the subjective and objective portions of the note.
2. Review the S and O portions of the note, jotting down or highlighting findings that are not WNL and
that can be influence or changed by therapy intervention. Medical of or psychiatric problems may be
part of the physicians problem list and may be listed in the problem area of the note (before the S),
but they do not belong in the therapy problem list.
3. Set priorities as to which problem is the most important, the next important, and so forth. It is
important to remember that the area of setting priorities involves judgments on the part of the
therapist.
4. List the physical therapy problems in order of priority.
LONG TERM GOALS:
Long term goals are part of the assessment section of the note. They state the product to be achieved by therapy.
Once the problem list is established, the patients long term goals are set.
Reasons for writing goals:
1. To help you plan the treatment to meet the specific needs and problems of t he patient,
2. To prioritize treatment and measure effectiveness,
3. To assist monitoring cost effectiveness, and
4. To communicate the therapy goals for the patient to other health care professionals.
Structure of a goal:
A. Audience: Who will exhibit the skills?
B. Behavior: What the person will do?
C. Condition: Under what circumstance- the position, the equipment, and so fort
Must be provided or be available for the patient to perform the given behavior.
D. Degree:
How well the behavior be done- number of feet, number of repetitions, muscle grades,
degree of ROM; the amount of improvement you want to see specifically)
Clarity:
Poorly written goals do not clearly communicate the purpose of your treatment.
Revision:
Occasionally, long term goals may require revision if:
1. The patients condition changes and will not allow progression to the functional level originally set,
2. The patients condition changes and allows progression to the functional level originally set, or
3. The time span set is no longer appropriate and should be revised.

SHORT TERM GOALS:

Short term goals are part of the Assessment portion of the note. They are interim steps along the way to
achieving long term goals. Once the expected final outcomes of therapy have been determined, the short term
goals are then set. The specific treatment regimen is designed to achieve the short term goals.
Reasons for writing goals:
1. To direct treatment to the specific needs and problems of the patient,
2. To prioritize treatment and measure the effectiveness of treatment,
3. To assist with cost effectiveness,
4. To communicate the therapy goals to other health care professionals.
Short term goals help to guide the immediate treatment plan. Periodically reviewing and resetting short term
goals helps the therapist and the patient realize the progress that the patient has made.

V. PLAN
The plan portion of the notes contains the plan for the patients treatment.
Information included under plan:
The following information MUST be included in the plan section of the note:
1. Frequency per day or per week that the patient will be seen.
2. The treatment that the patient will receive
3. If a discharge note, where the patient is going and the number of times the patient was seen in
therapy.
The following are also frequently included in the plan section:
1. The location of the treatment.
2. The treatment progression.
3. Plans for further assessment or reassessment.
4. Plans for discharge.
5. Patient and family education.
6. Equipment needs and equipment ordered/sold to the patient.
7. Referral to other services.