Documenting Reason for Referral: Background Information and Health Condition,

Documenting Reason for Referral

Background Information and Health Condition

LEARNING OBJECTIVES

After reading this chapter and completing the exercises, the reader will be able to:

1. Identify and classify various aspects of documenting a patient’s background information and health condition.

2. Explain the three key elements of describing a patient’s current health condition.

3. Discuss the implications of direct access for documenting medical diagnoses.

Within the scope of their practice, PTs encounter patients with a variety of health conditions. Health condition, as defined by the ICF framework, is an umbrella term for disease (acute or chronic), disorder, injury, or trauma (Figure 5-1). It may also include other circumstances, such as pregnancy, aging, stress, fitness level, congenital anomaly, or genetic predisposition. Health conditions can result from infections, acute injuries, metabolic imbalances, or degenerative disease processes.

FIGURE 5-1 This chapter discusses documentation pertaining to Health Condition (disorder/disease) based on the ICF framework.

Any physical therapy initial evaluation note must provide specific information about the medical diagnosis or known or suspected pathologic conditions. Because it may be pertinent to the patient’s referral to physical therapy, the health condition must be presented in a clear and concise fashion in the PT’s documentation.

In the Guide to Physical Therapist Practice (American Physical Therapy Association [APTA], 2001; the Guide), information pertaining to a patient’s health condition is categorized under “History” in the Examination Section. The Guide defines history as follows:

The history is a systematic gathering of data—from both the past and the present—related to why the patient/client is seeking the services of the physical therapist.… While taking the history, the physical therapist also identifies health restoration and prevention needs and coexisting health problems that may have implications for intervention (p. S34).

Thus the relevance of history taking, as it relates to the health condition, is that it provides the foundation for why the patient or client is referred for physical therapy, thus setting up the reason for referral. What are the specific medical diagnoses, health problems, or health risk factors that bring the patient to seek the services of a physical therapist?

This chapter discusses documentation of Reason for Referral as it relates to the health condition. Readers will have an opportunity to practice writing statements related to health condition and appropriately identify information that belongs in this section of a report.

Documenting Elements of Health Conditions

In general, health condition information is included early in an evaluation because these data are critical to determining how the PT should proceed with the examination. Therapists perform a process known as differential diagnosis, in which they gather information to confirm or modify any previously determined diagnoses (from other health care professionals) or develop their own diagnosis (see Chapter 9 for more information on diagnosis by PTs). In addition, therapists will ask pathology-related questions, which help identify possible problems that require consultation with or referral to another provider. Certain conditions raise concerns about whether an underlying condition exists in which physical therapy may be contraindicated or in which referral to another health professional would be warranted.

Detailed information about the health condition is therefore an important part of determining the appropriateness of physical therapy as an intervention. Certain health conditions are appropriate for physical therapy; others are not. However, diagnosis alone does not determine the appropriateness of intervention; instead, the associated or secondary limitations or impairments related to a diagnosis warrant physical therapy intervention.

In some ways, the health condition information documented by the PT in this section is somewhat limited. At this point, the therapist simply classifies any facts he or she has available before the examination is performed. As the examination proceeds, the PT may uncover information that may help to refine any previously given diagnosis. Any new information obtained during the course of the physical therapy examination that confirms, clarifies, elaborates on, or possibly contradicts the established diagnosis and health condition should be documented in the appropriate section (e.g., Impairments, see Chapter 8) and summarized in the Assessment section (see Chapter 9). Thus information about health conditions and diagnosis does not begin and end in this section.

Information about a patient’s health condition can be organized in the initial evaluation note in many ways. Different institutions frequently mandate a certain organizational structure, and this is often preprinted on customized initial evaluation forms. The degree to which each of these headings is used differs depending on the institution and patient population. For the general initial evaluation, the following categorization of information is recommended to document health condition and the reason for referral:

• Patient information and demographics

• Current condition

• Past medical history

• Medications

• Other (family or developmental history, as pertinent)

Table 5-1 provides a detailed listing of the types of information that can be included in each of these categories. Case Examples 5-1 through 5-3 at the end of this chapter provide sample documentation in different clinical settings.

CASE EXAMPLE 5-1

Setting: Outpatient

Name: Ally McCarthy D.O.B.: 9/25/44 Date: 12/11/09 Sex: F

CURRENT CONDITION:

Pt. was referred by Dr. Hull for eval and Rx related to low back dysfunction. Pt. reports sudden onset of LBP after lifting heavy boxes 12/1/09. Pt. sought medical advice from Dr. Hull 3 days later on 12/4/09. Dr. Hull prescribed x-rays, which revealed L2-5 DDD as per phone conversation with Dr. Hull. Pt. was then prescribed Flexoril and referred to PT. Pt. reports h/o generalized LBP over past 10-15 yr; Rx c– various anti-inflammatories and several episodes of PT intervention c– symptoms resolving p– 1 mo. on average.

NIDDM ×5 yr; R ACL reconstruction Nov. 2000; no complications and no limitations on activities related to this surgery.

Flexoril (muscle relaxant for LBP; 10 mg table, 3 t.i.d.).

TABLE 5-1

Components of Documenting Reason for Referral

Component	Information Included
*Patient information and demographics*	Patient’s name Date of birth Sex Demographic information, such as race or ethnicity (if relevant)
*Current condition*	Reason patient is referred, if not evident Concerns that led the patient to seek services of a physical therapist Current and prior therapeutic interventions (if any) Mechanisms of injury or disease, including (see Table 5-2): Underlying disease process Location Time course < div class='tao-gold-member'> Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Legal Aspects of Documentation Documentation in Pediatrics Treatment Notes and Progress Notes Using a Modified SOAP Format Essentials of Documentation Documenting Impairments in Body Structure and Function Documenting Goals Stay updated, free articles. Join our Telegram channel Tags: Documentation for Rehabilitation A Guide to Clinical Decision Jun 22, 2016 \| Posted by admin in PHYSICAL MEDICINE & REHABILITATION \| Comments Off on Documenting Reason for Referral: Background Information and Health Condition, Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access