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At the completion of this chapter, the reader will be able to:

  1. Understand the various components of an initial examination document

  2. Be able to recognize the most important information from the medical record

  3. Recognize various common abbreviations

  4. Use a structured thought process to assimilate information from a typical medical record

  5. Appreciate that most patients present with more than one diagnosis

  6. Formulate an approach for the first visit with a patient


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.

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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Name: Gladys Night Precautions: Monitor SpO2 with ADLs
Admission diagnosis:

COPD (J 44.9)

CHF (I50.9)

Weight-bearing Status: WBAT
Date of admission: Mar 16, 2021 BMI: 31 (slightly obese)
Date of birth: Feb 21, 1936 Living Situation: Lives alone in bungalow
Age: 85 Prior Level of Function: IND
Sex: F Assistance Available at Home: Very limited, but the neighbor checks in every day. Son and daughter live in different states
Medical Record #: 555-45213 Physical barriers at home: Lives on one level. 2 steps to get into the house
Attending Physician: Dr. G. Altman Assistive Device Used Before Admission: FWW
Room #/Bed #: 403/2 Prior Driving Status: Unable to drive
Isolation: N/AP Primary Language: English
Medication Allergies: Penicillin Occupation/Life role: Home keeper
Food Allergies: NKA Demographics: Widow for 20 years. Regular churchgoer. Very social
Diagnostic Test Results: CXR reveals hyperinflation Laboratory Results: pH 3,75; PaCO2 39 mm Hg; FiO2 0.21; BUN 10, creatinine 0.4
Current medications: Albuterol nebulizer (PRN), theophylline (400 mg PO once daily), Lasix (50 mg PO once daily), bisoprolol (5 mg PO once daily)
Pertinent information for the PTA: The PTA needs to focus on any information that is going to impact a physical therapy intervention (weight-bearing status, prior level of function, the assistive device used before admission), and try to determine whether any of the medications, or the laboratory or diagnostic test results could impact any increase in the patient’s ...

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