At the completion of this chapter, the reader will be able to:
Understand the principles and considerations of a comprehensive examination.
List the components involved in the continuum of care.
Take a complete history.
Explain the importance of the systems review.
List the components of the tests and measures portion of the examination.
Understand the value of a complete observation of the patient and the information that can be gleaned from such an assessment.
Describe the differences between a traditional examination and a postsurgical examination.
Explain the differences between the examination and the evaluation.
Explain how to determine whether a technique is clinically useful.
Outline the components of clinical documentation.
Patient/client management comprises five elements:1
Examination of the patient
Evaluation of the data and the identification of problems
Determination of the diagnosis
Determination of the prognosis and the plan of care (POC)
Implementation of the POC (intervention)
The examination process involves a complex relationship between the clinician and the patient. The aims of the examination process are to provide an efficient and effective exchange and to develop a rapport between the clinician and the patient. The success of this interaction involves a myriad of factors. Successful clinicians are those who demonstrate effective communication, sound clinical reasoning, critical judgment, creative decision making, and competence.
The primary responsibility of a clinician is to make decisions in the best interest of the patient. Although the approach to the examination should vary with each patient, and from condition to condition, there are several fundamental components to the examination process. The principles outlined in this chapter, and integrated throughout this text, are based on the views of a number of experts,2–12 as well as principles I have learned, and used, over the years.
All clinicians should commit to be lifelong students of their profession and should strive toward a process of continual self-education. Part of this process involves the utilization of the expertise of more experienced clinicians. This necessitates that the early years of practice are spent in an environment in which the novice is surrounded by a staff of varying levels of clinical and life experiences, both of which can serve as valuable resources. The clinician can also improve by investing time in reading relevant material, attending continuing education courses, completing home study courses, watching videos specializing in techniques, and observing exceptional clinicians. Exceptional clinicians are those who demonstrate excellent technical skills, combined with excellent people skills.
From the patient's point of view, there is no substitute for interest, acceptance, and especially empathy on the part of the clinician.13
Finally, one must also never forget that the patient can serve as the most valuable resource. Each interaction with a patient is an opportunity to increase knowledge, skill, and understanding. Integral to this relationship is patient ...