The document discusses the importance of documentation in physical therapy, including having a complete patient history, demonstrating clinical reasoning, justifying treatment, and maintaining communication. It also provides examples of subjective information to collect from patients, objective examination findings, and functional assessment tools to evaluate patients and measure outcomes. The document emphasizes using standardized tests and measures to accurately identify impairments, functional limitations, and their impact on daily activities.

1. Documentación en
Fisioterapia
Licenciatura en
Fisioterapia
LTF. A Yohali Burrola Méndez

2. Razones para documentar

3. ¿Por qué es importante documentar?

4. Razones para documentar
• Tener un historial completo del paciente
• Demostrar la solución de problemas y el
razonamiento clínico
• Tramitar reembolsos
• Justificar la necesidad de una intervención
especializada
• Mantener la comunicación
• Investigación de resultados
• Acciones legales

5. Serie de pasos
interrelacionados
Planear una intervención
efectiva
Necesidades y
objetivos
del paciente
Miembros del
equipo
de salud
Modelo de intervención paciente/cliente para la obtención de
resultados óptimos

6. Examinación
Evaluación
Diagnóstico
Pronóstico
Intervención
Resultados
Modelo de intervención APTA
APTA, Guide for Physical Therapist Practice

7. Documentación en el encuentro inicial
•Procesos de recopilación
de datos sobre el
paciente o cliente.Examinación
•Toma de decisiones y
juicios clínicos realizados
por el FT basados en la
examinación.
Evaluación

8. • La examinación y la evaluación se utilizan
erróneamente como sinónimos.
• Las dos forman la evaluación inicial.
• El proceso de recolección de datos es
clasificado como subjetivo y objetivo.

9. Información subjetiva:
• Proporcionada por el
paciente, familiar,
cuidador.
• Incluye la historia
clínica, el problema
que abordará la
Fisioterapia y el motivo
de derivación.

10. • Historia del presente padecimiento, mecanismo de
lesión, fecha de inicio, estilo de vida del paciente,
los objetivos del paciente dentro de la Fisioterapia

11. • Ejemplo 1
Example 1. Sample of Subjective Documentation from Initial Encounter
Patient name: Becky Smith
Date of service: August 1, 2007
Date of injury: July 4, 2007
Pr: (R) humerus fracture; Refered to PT for shoulder and elbow PROM, sling on at all other times
Subjective: HPI: 67 y.o. white, right-hand dominant, female, 4 weeks s/p fall from chair while
changing light bulb during which she sustained a (R) spiral humerus fracture. Immediately underwent
ORIF and was placed in a ling. L/S: Pt lives in two-story home with her husband. She has 2 grown
children living nearby who can provide assistance. Pt. is a retired teacher who substitute teaches
occasionally. Pt. plays recreational tennis and walks daily. She has been unable to perform normal
ADLs including self-care, home management, driving, or exercising since the DOI Pt.’s Goal: Return to
her normal active lifestyle. PMH: unremarkable. Pt. is a non-smoker and reports being in good health.
She had a hysterectomy 15 years ago. C/C: Pain with motion of the (R) arm movements and difficulty
performing self-care skills 2 to being unable to use her (R) arm. Reports using OTC ibuprofen for
pain.

12. • Actividad 1
– Revisar el Apéndice A del libro Physical Therapy
Documentation donde la The Guide to Physical
Therapist Practice sugiere la ampliación de la
información subjetiva considerando otros aspectos.
– Elaborar una ficha de documentación subjetiva del
primer encuentro de un paciente dentro del campo
clínico

13. • Ejemplo 2
Example 2. Sample of Systems Review Documentation from Initial Encounter
Patient name: Becky Smith
Date of service: August 1, 2007
Date of injury: July 4, 2007
Pr: (R) humerus fracture; Refered to PT for shoulder and elbow PROM, sling on at all other times
Subjective: HPI: 67 y.o. white, right-hand dominant, female, 4 weeks s/p fall from chair while changing light
which she sustained a (R) spiral humerus fracture. Immediately underwent ORIF and was placed in a ling. L/S: Pt
lives in two-story home with her husband. She has 2 grown children living nearby who can provide assistance.
Pt. is a retired teacher who substitute teaches occasionally. Pt. plays recreational tennis and walks daily. She has
been unable to perform normal ADLs including self-care, home management, drive, or exercise since the DOI
Pt.’s Goal: to return to her normal active lifestyle. PMH: Unremarkable. Pt. is a non-smoker and reports being in
good health. She had a hysterectomy 15 years ago. C/C: Pain with motion of the (R) arm movements and
difficulty performing self-care skills 2° to being unable to use her (R) arm. Reports using OTC ibuprofen for pain.
ROS: Cardiopulmonary system: HR: 88, BP: 128/88, RR: 10. Integumentary system: Incision healed, immature
present along posterior humerus. Musculoskeletal system: Pt. is 5’7’’ and 155#. (R) UE held at her side in a sling,
decreased (R) shoulder and elbow AROM, (R) AROM wrist and hand is WNL. All (L) UE and cervical AROM is
WLN. Neuromuscular system: She ambulated (I) into the clinic without difficulty. Gross sensation to light touch
(B) is intact. Communicates without difficulty.

14. • Actividad 2
– Elaborar una ficha de documentación objetiva
(revisión de sistemas) del paciente previamente
examinado.

15. • Basándose en la información obtenida
durante la revisión de los sistemas, el FT
selecciona y realiza pruebas más específicas
con el objetivo de:
– Identificar y medir con precisión alteraciones en
el movimiento
– Deficiencias funcionales
– Limitaciones en tareas de la vida diaria.

16. • Estas mediciones serán cruciales para establecer el
diagnóstico, pronóstico y plan de tratamiento.
• Revisar The Guide to Physical Therapist Practice,
documentation of Patient/Client Management, que
sugiere una lista de tests específicos.
• Ejemplos: ROM, flexibilidad, sensibilidad, balance
muscular, circulación, etc.

17. Ejemplo 3
Example 3. Sample of Tests and Measures (Impairments) Documentation
from Initial Encounter
Patient name: Becky Smith
Date of service: August 1, 2007
Date of injury: July 4, 2007
Pr: (R) humerus fracture; Refered to PT for shoulder and elbow PROM, sling on at all other times
Subjective: HPI: 67 y.o. white, right-hand dominant, female, 4 weeks s/p fall from chair while changing light bulb
which she sustained a (R) spiral humerus fracture. Immediately underwent ORIF and was placed in a sling. L/S: Pt
lives in two-story home with her husband. She has 2 grown children living nearby who can provide assistance. Pt.
is a retired teacher who substitute teaches occasionally. Pt. plays recreational tennis and walks daily. She has
been unable to perform normal ADLs including self-care, home management, drive, or exercise since the DOI
Pt.’s Goal: to return to her normal active lifestyle. PMH: Unremarkable. Pt. is a non-smoker and reports being in
good health. She had a hysterectomy 15 years ago. C/C: Pain with motion of the (R) arm movements and difficulty
performing self-care skills 2° to being unable to use her (R) arm. Reports using OTC ibuprofen for pain.
ROS: Cardiopulmonary system: HR: 88, BP: 128/88, RR: 10. Integumentary system: Incision healed.
Musculoskeletal system: Pt. is 5’7’’ and 155#. (R) UE held at her side in a sling, decreased (R) shoulder and elbow
ROM, (R) AROM wrist and hand is WNL. All (L) UE and cervical AROM is WLN. Neuromuscular system: She
ambulated (I) into the clinic without difficulty. Gross sensation to light touch (B) is intact. Communicates without
difficulty.
Tests and measures: Capillary refill: intact Integumentary integrity: immature adhered scar present along
posterior humerus, dry, hypersensitive to touch, raised ~1-2 mm Strength: (L) UE 5/5; (R) UE N/A this visit 2° to
surgery Pain rating: at rest 2/10, at worst 6/10 PROM: (R) shoulder: flexion 95° abduction 90° ER 35° IR 50°; elbow:
-10/100°; (L) shoulder: flexion 160° abduction 160° ER 90° IR 70°; elbow 0/140°

18. • Con el cambio hacia la función y el impacto de la
discapacidad, el uso de instrumentos
estandarizados de evaluación funcional se ha
vuelto más popular.
• Examinar y documentar el estado funcional
proporciona información sobre el impacto de las
patologías, el contexto sociocultural y las
alteraciones en las actividades de la vida cotidiana.

19. • La presencia de restricciones o limitaciones
no siempre conllevan un impacto funcional.

20. Ejemplo 4
Example 4. Sample of Tests and Measures (Funtion) Documentation
from Initial Encounter
Patient name: Becky Smith
Date of service: August 1, 2007
Date of injury: July 4, 2007
Pr: (R) humerus fracture; Refered to PT for shoulder and elbow PROM, sling on at all other times
Subjective: HPI: 67 y.o. white, right-hand dominant, female, 4 weeks s/p fall from chair while changing light bulb
which she sustained a (R) spiral humerus fracture. Immediately underwent ORIF and was placed in a sling. L/S: Pt
lives in two-story home with her husband. She has 2 grown children living nearby who can provide assistance. Pt.
is a retired teacher who substitute teaches occasionally. Pt. plays recreational tennis and walks daily. She has been
unable to perform normal ADLs including self-care, home management, drive, or exercise since the DOI Pt.’s Goal:
to return to her normal active lifestyle. PMH: Unremarkable. Pt. is a non-smoker and reports being in good health.
She had a hysterectomy 15 years ago. C/C: Pain with motion of the (R) arm movements and difficulty performing
self-care skills 2° to being unable to use her (R) arm. Reports using OTC ibuprofen for pain.
ROS: Cardiopulmonary system: HR: 88, BP: 128/88, RR: 10. Integumentary system: Incision healed. Musculoskeletal
system: Pt. is 5’7’’ and 155#. (R) UE held at her side in a sling, decreased (R) shoulder and elbow ROM, (R) AROM
wrist and hand is WNL. All (L) UE and cervical AROM is WLN. Neuromuscular system: She ambulated (I) into the
clinic without difficulty. Gross sensation to light touch (B) is intact. Communicates without difficulty.
Tests and measures: Capillary refill: intact Integumentary integrity: immature adhered scar present along posterior
humerus, dry, hypersensitive to touch, raised ~1-2 mm Strength: (L) UE 5/5; (R) UE N/A this visit 2° to surgery Pain
rating: at rest 2/10, at worst 6/10 PROM: (R) shoulder: flexion 95° abduction 90° ER 35° IR 50°; elbow: -10/100°; (L)
shoulder: flexion 160° abduction 160° ER 90° IR 70°; elbow 0/140°
Functional assessment: DASH questionnaire score 84/100, see attached; Requires assistance with ADLs including
hygiene, dressing, and bathing; unable to complete home management tasks, drive, work, or participate in normal
recreation activities, i.e., tennis, walking program.

21. • Actividad 3:
– Seleccionar y evaluar pruebas específicas en el
paciente reportando los resultados obtenidos en
el mismo formato.
– Del libro Evaluación clínico funcional del
movimiento corporal, revisar del Capítulo 12 –
Valoración de la capacidad funcional – las
pruebas de valoración funcional expuestas,
seleccionar una y aplicarla al paciente.