Physical therapy assessments and forming a detailed case based on the assessment outcomes are a crucial part of ensuring proper treatment for your patients – and may also uncover some knowledge that may help you understand your patient better. Failing to perform assessments or basing treatment on assumptions can be dangerous – potentially even leading to negative outcomes. Read on for more information about therapy assessments and how they are essential to therapy providers.
What are Therapy Assessments?
Simply put, a therapy assessment aims to give a probable reason why a therapist provided a certain treatment to a patient. The assessment highlights why the patient is in dire need of skilled therapy and identifies areas that should be addressed during the next visit.
While drafting the therapy assessment documentation, you’re required to write a summary of the patient’s ability or inability to perform certain tasks. An excellent assessment is indicated when there is a link between the chosen treatments and functional goals for the patient.
Why Are Therapy Assessments Important to Physical, Therapy Providers?
As a clinician, it’s key to understand that assessments give you a practical opportunity to take a more objective approach when treating your patients. Here’s a few reasons why therapy assessments will enhance your practice:
Ability to Check and Challenge Patient Diagnoses
Earlier, we mentioned the danger of treating patients without conducting a comprehensive therapy assessment. By conducting a therapy assessment, you can come up with evidence-based diagnoses, thus offering proper treatment to patients, and peace of mind that your decision is based on more than just assumption.
Clarification of Necessary Interventions
Some patients might be weary of treatment and may try to present themselves as healthy by concealing their ailments. So how can you unmask true physical problems that need attention? By conducting an in-depth therapy assessment, an interview or questionnaire may not be enough for such patients; they need keen clinical intervention to determine the root cause and extent of their ailment.
Providing Data to Build a Collaborative Treatment Plan
Formulating a list of therapy assessments that will guide the treatment process helps create a rapport between you and the patient going forward. When the patient responds positively to your assessment and offers truthful information, your work will be made easier, and the recovery process more efficient.
Opportunity to Engage with Patients on a Deeper Level
By utilizing physical therapy assessments, you have the opportunity to actively engage with patients and ask meaningful questions. Listening to their issues and helping them work through them can bring feelings of great satisfaction to you as the provider. Hopefully the patient will also experience relief as you take steps towards healing and a positive outcome together.
Therapy Assessment Types
Physical Therapy Assessment
Physical therapy clinicians engage patients in an assessment process that includes:
- Noting down the patient’s medical history
- Reviewing the notes, test results, and medications from other practitioners if any
- Performing a comprehensive systems review through hands-on tests to establish if there are any potential or existing conditions
It’s now time to establish the diagnoses, plans of care, and prognoses. To do that, you should evaluate, synthesize the exam data, and ascertain whether the problems at hand are within your scope as a physical therapist.
Here’s a good checklist to follow:
- Diagnose the patients’ movements and functions. Observe how the patients walk or perform certain tasks, then conduct various tests, and hear their side of the story.
- Design a customized care-based plan according to your medical expertise, research, and expected results.
- Apply such techniques as hands-on therapy, exercises, and tools to reduce the pain and accelerate the recovery process.
- Evaluate patients’ progress and modify the care plan when necessary
- Create awareness (to the patients and their families) of what to expect and how to respond during recovery
- Formulate a discharge plan.
Occupational Therapy Assessment
As an occupational therapist, before treating an injured, sick, or disabled patient using everyday therapeutic activities, you need to conduct an all-round assessment. This includes:
- Reviewing patients’ medical history
- Evaluating their current condition and needs
- Formulating a care-based treatment plan
- Assisting patients with various disabilities perform certain tasks/ exercises. Example: Helping stroke victims re-learn to dress themselves
- Assessing the patients’ workplace or residence, and suggesting certain improvements based on their health needs
- Educating the patient’s employer and/or family on how to care for and accommodate the patient
- Recommending aiding tools like the wheelchairs or eating aids
- Recording and assessing the patient’s progress and developing a discharge plan
Speech Therapy Assessment
With many speech therapy patients being children, you’re expected to assess their parents or legal guardians in addition to observing and testing the patient. Here are some important questions to ask and assessments to make:
- Ask the parent if the child has any medical issues, e.g., regular ear infection
- Conduct informal or formal tests to determine how the patient articulates words, constructs sentences, and undertakes questions
- Pay attention to the patient’s voice quality
- Test the patient’s reading speed, comprehension, and word discrimination
A2C and Therapy Assessments
Whether you’re a physical, occupational or speech therapist, the evaluation procedures we’ve discussed above are essential for a positive outcome for your patients. A2C Medical, an EMR software for physical, occupational and speech therapy, can help you document your assessments electronically so you can formulate evidence-based treatment plans and easily share them with other providers. Additionally, our system can even pull data into easy to understand reporting for billing purposes. Your clinic deserves the best EMR software. Visit our blog and learn more about A2C Medical today!