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CHAPTER OBJECTIVES
At the completion of this chapter, the reader will be able to:
Understand the various components of an initial examination document
Be able to recognize the most important information from the medical record
Recognize various common abbreviations
Use a structured thought process to assimilate information from a typical medical record
Appreciate that most patients present with more than one diagnosis
Formulate an approach for the first visit with a patient
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A physical therapist assistant (PTA) must be able to transfer classroom knowledge to the clinic. Part of that ability involves interpreting the supervising physical therapist’s documentation and then putting that interpretation into action. The electronic health record (EHR) of a patient with multiple diagnoses is used as an example, as are standard abbreviations (Table 4-1). Various pointers are provided throughout the document to give insight into the thought processes and methods used by a physical therapist (PT) as they complete their initial examination and to emphasize that the PTA should accumulate insights throughout the document review.
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The patient used in this example is an 85-year-old female admitted to an acute care hospital with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). It is extremely uncommon in the acute care setting to find a patient with a single diagnosis, and most will have several comorbidities, each of which can impact their treatment.
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