Outcome 6
Perform data collection essential for carrying out the plan of care under the direction and supervision of the physical therapist
Criteria
6.1.
choose appropriate measures for neurological, musculoskeletal, cardio-pulmonary, and integumentary conditions
6.2.
perform subjective and objective data collection accurately and efficiently
6.3.
document results accurately, including communicating relevant findings to appropriate members of the health care team as needed
Reflections...
When working with patients it's imperative that you document both objective and subjective findings. An example of objective findings would be the many measurements that must be taken of a post operative residual limb of a patient that is being prepared for a prosthesis. Things like girth, range of motion, skin integrity and strength must all be recorded, monitored and compared as the person progresses through the healing process. For PTA Management of Cardiopulmonary & Integumentary Issues, one of our assignments was to create a chart that could be used to capture that type of data. I have included it below.
Another documentation tool is the flowchart. I created one to use with my Keep Stepping Client to make it easier to track her performance during walking, circuit exercises, warm-up, cool-down and vitals. I kept track of skilled intervention such as cues and level of assistance. I also recorded subjective data like her PRE and comments she made. This was a great aid in completing my SOAP notes.