The document describes two methods for documenting patient medical records: SOAP format and POMR (Problem Oriented Medical Record). SOAP format involves documenting subjective findings reported by the patient, objective findings observed by the therapist, an assessment of the subjective and objective findings, and a treatment plan. POMR was developed by Weed as an alternative method. It divides patient treatment into four phases: collecting an initial database, listing identified problems, identifying a treatment plan for each problem with progress notes, and assessing treatment plan effectiveness and changes over time. It focuses documentation around identified patient problems.

1. DOCUMENTATION
 SOAP format, is a way of documenting a patient condition along with his/her
progress notes.
S- Subjective findings are what the patient or his/her family members
report.
O- Objective findings are what the therapist observes, tests and measures.
A- Assessment includes professional judgement about the subjective and
objective findings formulated into both short term and long term goals.
P- Plan, includes both general and specific aspects of treatment.
 POMR stands for Problem Oriented Medical Record Keeping.
It was developed by ‘Weed’ as an another method of documenting patient notes.
It divides a patient’s treatment into four phases.
PHASE I- The database includes: (A) History (B) Physical Examination
(C) Laboratory and Other Assessment Results.
PHASE II- Problem listing, which includes specific impairment of
functions i.e., physical, physiological and psychological function problems.
PHASE III- Identification of a treatment plan for each problem which has
been described with evaluation and progress note for each.
PHASE IV- Assessment of the effectiveness of each of the plans and
subsequent changes in these plans as a result of the patients progress.
POMR thus highlights the relationship of the database to the treatment plan
and allows specific patient problems to become the central focus of planning.

2. ASSESSMENT
I. SUBJECTIVE
A. Demographic details:
Name: 1. Where he/she belongs
2. Male/female
3. Initial introduction to therapist
Age: 1. Predict age related diseases
2. congenital diseases
Eg: OA, CTEV
Gender: Gender related diseases, eg: OA, PIVD
Address: How is the communication from home to clinic, locality, offers insight into
pts socio economic status.
Occupation: Conditions owing to certain occupations. Eg: CS, AC, LE etc.
Body Mass Index(BMI): Pts. Are classified accordingly into ectomorphic,
mesomorphic and endomorphic.
B. Chief Complaint: Depends on 3 parts:
 Pain
 Restriction of ROM- due to pain or shortening of the periarticular structures.
 Functional limitations
** c/c documentation is always noted in the patients own language and as per priority of
the patient.
C. History:
1. h/o present illness: onset, duration, aggravating and relieving factors (acute/ sub-
acute/ chronic), associated symptoms(vomiting, seizures, headache, nausea, etc)
2. h/o past illness: past major illnesses eg. jaundice, typhoid etc.; previous
hospitalization, pregnancy, etc.
3. Associated medical/surgical history
4. Past surgical history
5. Socio-economic history: educational status, locality, financial status

3. 6. Environmental history: no. Of members? Floor of building? No. Of steps?
Attached toilet or no? Eg.- problem in step-down- tibio femoral OA; problem in step-up-
patello femoral OA.
7. Family H/o: genetic? Paternal or maternal h/o?
8. Personal history: Habits, Reproductive history, addiction.
9. Drug & Allergy H/o: eg: prolonged steroids and radiotherapy cause of
osteoporosis, etc.
10. Pain history:
 Side: rt/lft
 Site: ant./post/ med/lat
 Onset: gradual/sudden
 Nature: dull/vague/sharp/tingling/ radiating/referred
 Intensity: Check VAS
 Severity: Mild/Moderate/Severe
 Aggravating factors:
 Relieving factors:
 Body Chart:
 Consistency: constant/ intermittent
 Diurnal pattern:
 Irritability: factors that irritate or displace the pain so as to check tolerance.
11. Past & present medication: Choice and dosage of modality depend on it.
II. OBJECTIVE:
D. Observation:
 Gait abnormality: cicumductory(cva), hand to knee(pprp)
 Use of orthosis/prosthesis
 Facial expression
 Body Alignment: Posture assessment
 Deformity: structural, functional, dynamic. Eg: scoliosis
 Body contours; abnormal elevation of bones or congenital deformity. Eg.: genu
varus- space at lateral side of knee jt. Is more than medial side.
 Soft tissue contour: Occurs due to decrease no. of cells or decrease in volume of
cells(hypotrophy)- denotes muscle wasting, burns, keloids, scars.
 Limb Position: usually occurs post fracture or postural deviation.
**in lower crossed syndrome: abdominals and glutes are weak whereas
paraspinal and iliopsoas are tight.
 Skin contour/Texture: check for eruptions, incisional marks, burns, etc.
**ex- in peripheral neuropathy devitalization of skin at distal part of limb, the
skin looks scaly in appearance.
Posture,Activity,etc.

4.  Crepitus/ Abnormal sound/ Snapping:
 Swelling/ Redness:
III. ASSESSMENT
E. Examination:
Vital Signs: doses of ex. & choice of modality employed depends on it.
 Blood Pressure
 Heart Rate- rate rhythm, volume
 Respiratory rate- shows relaxation state of pt, respiratory pattern, phases of
inspiration and chest wall symmetry.
 Temperature
 Vertebra blazzial insufficiency is a contraindication of cervical traction where
blood circulation is interrupted through the artey tothe brain.
General Examination:
 Dermatomes: for superficial sensation
 Myotomes: for motor evaluation
 Neural Tension Test-Todetect neural compression or space occupying
lesions- tumors, CTS, TTS, piriformis syndrome, etc.
 Oedema
 Lymph Nodes
 Skin and mucous membranes: for cyanosis(central or peripheral)
 JVP
Systemic Review:
 Respiratory System: Chest expansion, tidal percussion, breath sounds,
percussion note(b/l)
 CVS: Apex beat, Heart sound, Murmur
 Abdomen: rigid or soft
EXAMINATION OF CNS:
 Level of consciousness – By GCS
 Memory- Remote memory, recent memory, immediate recall.
 Intellectual performance- attention, comprehension, insight,
judgement/reasoning, calculation, intellectual capacity.

5.  Emotional state- tense, bizarre, hesitant, depressed, euphoric, inappropriate,
negative, outburst, emotional lability.
 Content of thought: Worries, fears, preoccupied, obsession, fixed, delusion,
illusion, hallucination.
 Language of function: listening, speaking, writing, sample of handwriting.
CRANIAL NERVES:
I- OLFACTORY: SENSE OF SMELL, DISTINGUISHING SMELL
II- OPTIC: ACQUITY, COLOUR, FEILD, FUNDUS
III- OCCULOMOTOR: PTOSIS/SQUINT
IV- TROCHLEARPALPEBRAL FISSURE, CONJUGATE MOVEMENTS
V- ABDUCENS: PUPILS, EXTRA OCCULAR MOVEMENTS, NYSTAGMUS
VI- TRIGEMINAL: MOTOR- MASSETOR, TEMPORALIS, PTERYGOID(M+L);
SENSORY- TOUCH AND PAIN, CORNEAL REFLEX, JAW JERK
VII- FACIAL: MOTOR- UPPER & LOWER FACE, TASTE(ANT. 2/3RDS of tongue)
VIII- VESTIBULOCOCHLEAR: WHISPERED VOICE FROM 2FT, RINNES TEST,
WEBERS TEST, CALORIC TEST
IX- GLOSSOPHARYNGEAL: SENSATION IN THROAT, GAG REFLEX
X- VAGUS: PALATAL MOVEMENTS, VOICE, SWALLOWING
XI- SPINAL ACCESSORY: SCM, TRAPEZIUS
XII- HYPOGLOSSAL: DEVIATION, FIBRILLATION
MOTOR SYSTEM:
 Muscle wasting:
 Tone:
Grades 0: Flaccid
I: Hypotonicity
II: Normal
III: Hypertonicity
IV: Rigid/Spastic
Joint Specific Examination:
Joint AROM* PROM End-feel+
*AROM decreases due to intra articular pathogenesis, weakness or stiffness of muscle,
fracture- spasticity.
*In case of bony restrictions in a jt., PT is contraindicated.
*decreased AROM causes deviated gait pattern.
+End feel:

6. Springy block end feel: bounce felt at end range due to interrupting foreign
body.
Leathery end feel: due to capsular tightness.
Odd end feel: other than normal
Empty end feel: End feel can’t be checked due to pain.
MANUAL MUSCLE TESTING(MMT):
Grades 0, I,II,III,IV,V
Check for individual or group of muscles, MRC or Oxford or VMC used.
++Always check ROM and MMT for jts. Proximal and distal to affected jt.
RESISTANCE ISOMETRIC MOVEMENTS (RIM):
 It is used to detect pathology of contractile elements by asking patient to contract
isometrically for 10secs ideally.
 If contraction is,
STRONG AND PAIN FREE- Healthy muscle
STRONG AND PAINFUL- minor injury
WEAK AND PAINFUL- Major injury
WEAK AND PAINLESS- complete rupture/ neurological lesion
FUNCTIONAL ASSESSMENT WITH ANY STANDARDIZED FUNCTIONAL
SCALES:
Some scales are devised for certain conditions.
Every scale has specific scoring procedure depending on performance.
Ex—
 Knee- WOMAC scale
 Cervical spine/neck- NDI/ Neck Disability Index
 Low back pain- ODI/OswatiDisability Index
 Spinal Cord Injury- ASIA scale
REFLEXES:
Is of two types: Primitive(ATNR, STNR,etc); Superficial(Plantar, corneal, etc.) and Deep
Tendon Reflexes(biceps, supinator, etc.)
Grades-
0- Areflexia
1- Hyporeflexia
2- Normal
3- Exagerrated
4- Clonus(signs of hypertonia and UMNL)

7. JOINT PLAY MOVEMENT: Accessory movements, end feel changes due to jt. Play,
checked in loose pack position.
EXAMINATION OF CEREBELLUM:
 Finger nose test
 Finger to finger
 Heel knee
 Rapid alternating movement of hand
 Rapid alternating movement of finger
 Tandem walking
 Speech
 Rhomberg sign
FUNCTIONAL ASSESSMENT: By Barthel Index
DIFFERENTIAL DIAGNOSIS:
Ex- Shoulder pain can be due to: 1) supraspinatus tendinitis 2) bicipital tendinitis 3)sub
acromial bursitis 4) adhesive capsulitis 5)labral tears
Etc.,
Special Tests:
According to signs and symptoms, the therapist carries out specific tests to rule out
other possibilities and confirm a particular condition.
Investigations:
 Routine Blood Tests- CBC, LFT, HBAc, Fasting, PP, etc
**HLB27 is used for confirmation of ankylosing spondylosis, etc.
 X-RAY
 USG
 MRI
 CT SCAN
 EEG
 ECG
 EMG, etc.
FINAL DIAGNOSIS: Derived by ruling out other conditions via proper reasoning.
IV. PLAN:
After getting the final diagnosis, a plan of treatment is devised to meet the patients need.
 Short term plans

8.  Long term plans