General information edit
You should bear in mind that there are many variables that can affect the outcome of your assessment. The following is a (by no means exhaustive) list of possible factors influencing the patient (and condition) at the time of the session:
- Time of day (are they tired after work or feeling fresh in the morning)
- Temperature (extremes of hot and cold affect pain and stiffness)
- Position (if sitting relieves their pain and they sit down for 20 minutes, it may have disappeared by the time you try to assess it)
- Demeanour (if you’re abrupt with them, they won’t be very open with you)
The list goes on and on and it’s something that you’ll probably only begin to take note of as you gain experience. For now, just be aware that there’s more to the overall picture than what the patient says. Try to take notice of their body language as well as their verbal replies.
It’s important to make the patient feel as comfortable and relaxed as possible, as this will have a direct bearing on how open they are in discussing the problem with you. Remember, you’re probably going to ask them to remove at least a few items of clothing and to get into positions that in any other circumstances would be highly inappropriate. Think carefully about what you’re saying, as while it may be technically correct to say to the patient, “Take off your pants and bend over” when assessing the range of lumbar flexion, it may not be socially acceptable.
Use the subjective assessment as a period in which to make the patient feel calm and to try and create an atmosphere of trust.
Your assessment will almost always fall into 2 categories; the subjective and objective assessment. The subjective assessment, or interview, is used to try and work out the nature and cause of the patient’s symptoms. A good clinician will be able to get a very good idea of what’s going on just by speaking to the patient. The objective assessment is used both to eliminate other possible causes as well as to verify the hypothesis formed during the interview.
Personal details edit
Many outpatient settings will have their own forms for clinical notes. These differ greatly in layout but will always follow a similar sequence. The top of the form is usually reserved for the patient’s personal information, which is important to gather for the purposes of records. It usually consists of the following:
- Name and surname
- Date of birth
- Telephone number
- Date of referral
- Date of first appointment
- Referring doctor/consultant/physiotherapist
- There may be other information gathered, like medical chart number (if you're in a hospital setting), sex (‘male’ or ‘female’, not ‘often’), occupation and hobbies.