Demographic Information
also called the identifying information
this part helps us get a quick overview/picture of the patient
the details noted here tells us about the possible causes of the patient's injury
Patient's Name
usually written in full in the patient's chart
written in initials when used as part of teaching to protect the privacy of the patient
Age
helps us identify possible diseases that the patient have based on prevalent diseases of their generation
is the most common primary risk factor for disease
Sex
some diseases are more common in one gender than the other or occuring only in one gender.
Height, Weight, and BMI
this information is sometimes not included when getting demographic information
it is on the mandate of the hospital whether it should be recorded
are also indications for diseases which they play as risk factors
Occupation
tells the PT about the working environment of the patient as well as different actions and postures associated which could be causes of injury.
Handedness
gives an idea on the possible functional impairments during an injury.
Nationality
some races and ethnicities are at greater risk for diseases than other.
Attending Physician
this is the main doctor of the patient which refers them for rehab.
Physiatrist in Charge
this is the doctor in the rehab department which is in-charge of prescribing the patient's rehab plan
Chief Complaint
this is the symptom or concern that caused the patient to seek the treatment
most common in outpatient physiatric practice are: pain, weakness, or gait disturbances of various musculoskeletal or neurological origins
have the patient rank problems from "most bothersome" to "least bothersome"
Patient's Goal
to establish these may require the family or caregiver of the patient to step in during cases where the patient cannot speak for themselves or incapable of setting goals during their condition.
History of Present Illness
this section details the chief complaints for which the patient is seeking medical attention as well as any related or unrelated function deficits
should also explore other information relating to the chief complaint such as recent and past medical or surgical or procedures, complications of treatment, and potential restrictions or precautions
tells us the story of how the present complaint happen
primarily relates the sequence of events from the onset of the health problem up to the time
arranged in a chronological order
Mechanism of Injury
MOI
Ancillary Procedures
includes laboratory or radiology tests, and the dates and the findings of those tests
usually tabulated
Drug Hx
medications that the patient is currently taking
usually tabulated
Past Medical History
discusses all the other diseases related to the patient that was diagnosed before in his/her past
involves all pertinent and non-pertinent diseases
can also have a major impact on the rehabilitation outcomes
Family Medical History
for diseases related to the family/heredity
knowledge to know the general health of the family members can provide insight into their ability to provide functional assistance to the pt.
Red Flags
can be used to note the pt. for appropriate referral.
Personal, Social, and Environmental History
deals with knowing what the patient does outside the questions that were asked regarding diseases and medications.
Evidence Based-Practice
evidence-based medicine
the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients
evidence is used to inform more fully a decision-making process in which expertise provides one perspective to the clinical problem
means integrating the individual clinical expertise with the best available clinical evidence from systematic research
Traditional Practice
based on local or regional norms
"this is what i have always done for patients like this one"
Ask the Question
Aquire the Evidence
Appraise the Evidence
Apply the Evidence
Assess the Results
steps of evidence based-practice.
Ask the Question
by formulating an answerable question, you are able to focus your effort specifically on what matters
e.g. PICO, PEO, SPIDER, SPICE, etc.
PICO
is a question format that is useful for clinical and quantitative research topics.
Patient/Population/Problem Intervention Comparison Outcome
PICO
Clinical Practice Guidelines
statements that include recommendations intended to optimize your patient care
informed by a systemic review of evidence and an assessment of the benefits and harms of alternative care options
should follow a sound transparent methodology to translate best evidence into clinical practice to improve patient outcomes
are key aspects of a patient-centered care
Systematic Reviews
focuses on a specific clinical question and conducts an extensive literature search to identify studies with sound methodology
the studies are reviewed, assessed, and the results are summarized according to pre-determined criteria of the review question
Meta-analysis
takes a systematic review one step further by combining all the results using accepted statistical methodology .
Randomized Control Trial
a prospective, analytical, experimental study using primary data generated in the clinical environment
individual similar in the beginning are randomly allocated to two or more groups or the treatment or controlled group and then follow to determine the outcome of the intervention
Case Control Study
a study which patients who already have a specific condition or outcome are compared with people who do note
researchers look back in tome (retrospective) to identify possible exposures
often relies on medical records and patient recall for data collection
Cohort Study Prospective
a study of a group of individuals, some of whom are exposed to a variable of interest, in which participants are followed up over time to determine who develops the outcome of interest and whether the outcome us associated with the exposure.
Cohort Study Retrospective
when data is gathered for a cohort that was formed sometime in the past
exposures and outcomes have already occurred at the at the start of the study
you are studying the risk factor and see if you can associate a disease to it
individuals split by exposure
Cross-sectional Study
the observation of a defined population at a single point in time or during a specific time interval to examine associations between the outcomes and exposure to interventions
exposure and outcome are determined simultaneously and it often relies on data originally collected for other purposes
Survey Study
an epidemiologic study that produces survey results, and will consist of simultaneous assessments of the health outcome, primary risk exposure and potential cofounders and effect modifiers
e.g. cross-sectional and longitudinal studies
Case Series and Case Reports
descriptive study/studies that consist of collection of reports on the treatment of individual patients or a report on a single patient.
Descriptive Statistics
used to describe the study population using calculations, tables, and/or graphs
Mean
the sum of all values in a group/items in the group
average
Median
the value in the middle of a group of values.
Mode
the value that appears the most in a group of values.
Range
the simplest way to describe variation in a set of values - very sensitive to data that doesn't fit the typical pattern.
Interquartile Range
identifies variation in a set of values after removing outliers
reported as a range of numbers
Standard Deviation
identifies variation in a set of values by estimating the average distance of each score from the mean.
P-value
evaluates the statistical significance of the differences between the tow study groups or the relationships between two study variables.
T-test
evaluates the difference in means between 2 study groups for a specific thing (called variable).
Analysis of Variance
ANOVA
evaluates the difference in means between 3+ study groups for a specific variable
Confidence Interval
provides a level of certainty about the chance of error by identifying the range of values where the true population values lies
a 95% CI provides a 95% certainty that the true value lies within that range
Inferential Statistics
use data to make judgements about the difference between study groups for generalizing to the overall population.
Sensitivity
percentage of patients with disease who have a positive test for the disease in question.
Specificity
percentage of patients without disease who have a negative test for the disease in question.
Pre-test Probability
probability of disease before a test is performed.
Post-test Probability
probability of disease after a test is performed.
Likelihood Ratio
indicates an increase or decrease in the likelihood of disease.
Construct Validity
evaluates whether a measurement tool really represent the thing we are interested in measuring. it's central to establishing the overall validity of a method.
Content Validity
assess whether a test is representative of all aspects of the constrict.
Face Validity
considers how suitable the content of a test seems to be on the surface.
Criterion Validity
evaluates how well a test can predict a concrete outcome, or how well the results your test approximate the results of another test.
Critical Appraisal
is the process of carefully and systematically examining research evidence to judge its trustworthiness, its value and relevance in a particular context
allows clinician to use research evidence reliably and efficiently