From American Physical Therapy Association: The guide to physical therapist practice, ed 2, Alexandria, VA, 2001, American Physical Therapy Association.

When categorizing impairments, it can be useful to create headings that organize impairment documentation in an evaluation report or progress note. The Guide presents a categorization of the tests and measures used in physical therapy. These headings can be used for documentation purposes and provide a reasonable approach to organizing this section of an evaluation. However, impairments may be categorized in many ways depending on the patient’s medical condition, the facility, and the personal preferences of the therapist (see Case Examples at the end of this chapter).

Systems Reviews

A PT decides which impairments to measure based on the patient’s activity limitations and his or her underlying health condition. However, all PTs must perform certain basic assessment procedures and document them accordingly. One such set of measures includes a systems review.

A systems review is a “brief or limited examination of the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and the communication ability, affect, cognition, language, and learning style of the patient/client” (Guide to Physical Therapist Practice, 2001, p. S34). This may include communication skills, cognitive abilities, factors that might influence care, and learning preferences. A systems review typically also includes a cardiovascular screening for each patient, which can include an assessment of blood pressure and heart rate, and a general screen of range of motion and muscle strength. It is important to note that the information included in a systems review is a screening, and depending on the nature of the patient’s condition and the results of this screening, a more detailed assessment of these areas may be necessary.

For example, if an elderly patient is referred with shoulder pain, the following information would be important to include in a systems review: blood pressure/heart rate (cardiovascular), communication, and cognition (communication ability). In addition, skin assessment (integumentary), range of motion (ROM) and strength in the lower extremities in addition to the upper extremities (musculoskeletal), and any neurologic signs such as sensory changes or reflexes (neuromuscular), should also be assessed as part of a general screening.

The cases at the end of this chapter and in Chapter 4 provide examples of systems review documentation for different patient populations.

Strategies for Documenting Impairments

CHOOSING WHICH IMPAIRMENTS TO DOCUMENT

The general approach of this text is to evaluate and report those results that are relevant to the patient’s current condition and that are necessary to develop an adequate rationale for the diagnosis and intervention plan. If a patient is at risk for developing an impairment because of a particular medical condition, the absence of impairment should be documented. For example, in a patient with severe diabetes and associated peripheral vascular disease, the skin condition of the toes should be checked regularly and documented because tissue necrosis is a genuine risk in these patients.

SPECIFICITY OF DOCUMENTING IMPAIRMENTS

Quantifiable and objective data should be provided for impairment measures to be useful for diagnostic or evaluative purposes. Therapists should take care to document impairments with clarity and precision, avoiding vague and ambiguous terminology. Terms such as minimal, moderate, and maximal or good, fair, and poor are not particularly useful in descriptions of impairments and should be used sparingly in favor of more measurable, quantifiable assessments. Case Examples 8-1 to 8-3 give examples of documenting commonly assessed impairments in a concise but specific manner.

CASE EXAMPLE 8-3

Setting: Hospital Inpatient *

Name: Gareth Jones D.O.B.: 6/12/38 Date of Eval.: 8/2/09

CURRENT CONDITION

Pt. is a 71 y.o. male c― dx of COPD c― h/o frequent acute exacerbations.

IMPAIRMENTS

SYSTEMS REVIEW

ROM no limitations noted. B UE and LE; pt. is communicative and alert and oriented ×3. HR 130 bpm; RR 20 breaths/min; BP 148/88 mm Hg.

VENTILATION/RESPIRATION

Dyspnea, wheeze, productive cough (mucopurulent sputum); chest pain left side. Use of accessory muscles of inspiration, hyperinflated chest, Hoover’s sign, peripheral cyanosis, raised jugular venous pressure, pursed-lip breathing.

PALPATION

Limited thoracic expansion, decreased movement noted at the left lower zone, vocal fremitus on left.

PERCUSSION

Hyperresonant ++ all zones although ↓ resonance (dull) left base.

AUSCULTATION

Fine crackles and wheeze all zones, c/o plural rub left base.

TEST RESULTS

Spirometry: FEV₁ <40%. Arterial blood gases: pH 7.28, PaO₂ 8 kPa, PCO₂ 7.5 kPa, HCO^–₃ 32 mmol/L, base excess +4 (F_iO₂ 0.28). Chest radiograph: hyperinflated thorax, flattended diaphragm, consolidation/pleural effusion left base.

INTEGUMENTARY

Peripheral pitting edema noted in B LEs BK.

AEROBIC CAPACITY

Unable to stand due to breathlessness.

^*Note that in this example some different headings than those recommended by the Guide to Physical Therapist Practice are used. Therapists should choose headings that best fit the clinical setting in which they are working.

DOCUMENTING NORMAL FINDINGS

An assessment of body structures and functions must include documentation of the results of every test or measure that the therapist has performed, even if the findings were negative (i.e., normal). Documentation of normal findings can occur when the findings are directly relevant to confirming, refuting, or reshaping the medical diagnosis. For example, if a patient has pain in his or her shoulder and strength and ROM of the neck and shoulder are normal, these specific findings would be very important to document.

Therapists sometimes use two general terms, WNL (within normal limits) or WFL (within functional limits), to indicate “normal” or “typical” findings. The authors strongly discourage the use of WFL, as there is no accepted definition for this term and different professionals reading a note may interpret it in different ways. WNL should also generally be avoided, except when used to describe the results of a quick screening examination.

Standardized Tests and Measures

Many impairment-based measures used in physical therapy are quantitative. Therapists should carefully choose impairment-based measures that have established reliability and validity. Examples of some commonly used standardized tests and measures are listed in Table 8-1.

TABLE 8-1

Standardized Assessments of Impairments

Measure	Population	Purpose
Berg Balance Scale (Berg et al., 1992)	Any neurologic condition, the elderly, individuals with balance problems	Measures balance ability on 14 balance items, such as standing with eyes closed, turning in place, and standing on one leg.
Cincinnati Knee Rating System (symptoms) (Barber-Westin et al., 1984)	Patients with knee dysfunction	Measures symptoms related to knee pain, including pain, swelling, and giving way, on a 6-point scale.
Constant Murley Score (Constant & Murley, 1987)	Patients with shoulder dysfunction	100-point scoring system: 35 points derived from patient’s reported pain and function; 65 points from assessment of ROM and strength.
Fugl-Meyer (Fugl-Meyer et al., 1975)	Stroke	Based to a large extent on Brunnstrom’s (1996) description of the stages of stroke recovery; most items scored on a 3-point scale (0, 1, 2); includes motor function, sensation, ROM, and pain
Glasgow Coma Scale (Jennett & Teasdale, 1977)	Brain injury	Rates alertness and cognitive awareness in three categories (eyes, verbal, and motor).
Mini-Mental State (Folstein et al., 1975)	Any individual with cognitive deficits or dementia	Assesses several categories related to cognition, including memory, recall, and language.
NIH Stroke Scale (Goldstein et al., 1989)	Stroke	11-item clinical evaluation tool used to assess neurologic outcome and degree of recovery. Includes evaluation of level of consciousness, motor function, and language, among others.
Rate of Perceived Exertion (Borg & Linderholm, 1970)	Cardiopulmonary	Patients rate their perceived exertion level on a 15-point scale.
Short physical performance battery (Guralnik et al., 1994)	General population; elderly patients	Evaluates balance, gait, strength, and endurance by examining a patient’s ability to stand with the feet together in the side-by-side, semitandem, and tandem positions, time to walk 8 feet, and time to rise from a chair and return to the seated position five times.
Tinetti Gait and Balance (Tinetti, 1986)	Any neurologic condition, the elderly, individuals with balance problems	Developed as a screening tool to identify older adults at risk for falls. Balance component measures balance on eight specific tasks; gait component measures specific gait parameters during ambulation. All are scored on a 0 to 2 scale.