Term
| Categorizing Items as Subjective |
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Definition
ONLY INFORMATION THE PATIENT TELLS THE THERAPIST DIRECTLY. ANY Hx OUTSIDE OF THIS WILL BE DOCUMENTED IN THE O OR P SECTION.
1.current conditions/chief complaints 2.prior level of function 3.patient's goals 4.social hx 5.employment status 6.living environment 7.general health status 8.social/health habits 9.family health hx 10.functional status/activity level 10.medical/surgical hx 11.medications 12.growth and development 13.other clinical tests
14.response to treatment interventions 15. Anything else the pt. says that is relevant and significant. |
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Term
| Subjective info. is necessary to |
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Definition
| plan the objective assessment of the patient and to justify or explain certain goals that are set with the patient. |
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Term
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Definition
| the results of tests and measures performed and the therapist's objective observations of the patient are recorded. MEASURABLE, OBSERVABLE, REPEATABLE. |
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Term
| Cardiopulmonary info. tested (4) |
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Definition
| 1.heart rate 2.blood pressure 3.respiratory rate 4.general description of edema |
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Term
| Categories in Objective Notes |
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Definition
| 1.cardiovascular/pulmonary 2.Integumentary 3.Musculoskeletal 4.neuromuscular 5.communication style or abilities 6.Affect 7.Cognition 8.learning barriers 9.learning style 10.Education Needs 11.medical history (some places put it here, some only what pertains to the treatment plan, some don't include it) |
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