Subjective and Objective Assessment
Patient assessment in chest physiotherapy is not much different from other disciplines of medical information gathering
and analysis. The main aim of conducting an assessment is to recognise the main problem in our patient. When the problem has been recognized,
an accurate plan of trreatment can be initiated.
Correct patient assessment helps to plan for treatment that is effective and ethical. It also helps in time management.
Poor and innacurate patient assessment is both unethical and a waste of patient's time and resources.
Effective physiotherapy treatment calls for accurate assessment as well as a sound theoretical knowledge. It must also be appreciated that
patient assessment is an ongoing process to check if the treatment is producing the desired goals set initially.
After a thorough and complete assessment, treatment can be planned and commenced using the Problem Oriented Medical System(POMS).
POMS has three components:
- Problem Oriented Medical Records (POMR). With POMR, it is possible to record assessment, management and progress of a patient.
POMR is divided into five sections:
- Database. Database, as its name suggests contains information about the patient. It is a summary of the medical notes,
subjective as well as objective assessment. The first part has patient demographics, name of referring physician
and summary of the medical notes as well as that of the assessment by the Physiotherapist.
The second part contains:
- History of Presenting Complaint (HPC)
- Past Medical/Surgical History/Previous Medical/Surgical History
- Drug History
- Social History e.g do they smoke, how much support do they have at home?
- Family History e.g any close relative who suffered from the same illness
- Patient examination: informatio gathered after subjective and objective assessment
- Test results. Includes any information available. This could comprise of lab results (Full Blood Count-FBC, urinalysis), CT scan, MRI, X-Rays, etc.
- Problem List. After completing an assessment, problems are listed. It is a simple, functional and specific list of the
patient's problems at that time. Problems can be listed in order or not. Each problem is numbered and dated. It should also be noted that
problems listed ae not only those that can be managed by physiotherapy but also more medical problems like anaemia.
- Initial Plans. Having a clear list of problems, initial plans are set where goals for short and long term are formulated. These goals are specific, measurable, attainable, realistic and time-bound (SMART).
It is good practice to involve the patient. Since physiotherapy treatment involves the patient him/herslef, it is important to involve the patient in goal setting for treatment compliance.
A treament plan must be put in place for each goal set. A long term goal takes the patient to thei optimal functional level while short term goals
are the small goals which build up to achieve the long term goal. If goals are not achieved within the agreed time, it is necessary to do a revision.
- Progress Notes. These are notes written on daily basis using the SOAP format. S is for subjective assessment i.e what the nurses and doctors report.
O stands for Objective re-assessment i.e.any changes noted via physical examination or any investigations. A is for
Analysis. In analysis comprises of the physiotherapist's professional opinion based on subjective and objective analysis. P is for Plan. This plan may refer to change of treatment or course of action.
- Discharge Summary. At the end of hospital stay, discharge notes are recorded. They include patient's initial
problems, treatment and outcomes. Instruction for home programmes and any other relevant information should also be included to help those who will continue taking care of the patient.
- Audit = a systematic and critical analysis of the quality of care. It can be a structural audit, a process audit or an outcome audit. Structural audit bothers with organisation of resources in the setting, process audit focuses on the
referral systems in the setting while outcome audit bothers with effectiveness of treatment offered. This clinically important.
- Educational Programme. This follows problems noted in the process of patient care. It refers to education provided to members of staff in order to improve quality of care and treatment outcome.
This is a patient interview to hear their side of the story before any investigation is done. It should start with open ended questions.
This allows the patient to eveal problems which are more important to them. After the main problem has been revealed, it is the duty
of the clinician to probe more and more in order to understand the nature of the problem.
Cardiorespiratory/cardiopulmonary wise the following are the major symptoms:
- Dyspnoea (shortness of breath/breathlessness)
- Sputum or blood in sputum
- Chest pain
If a patient has any of the above problems, it is important to ask them how long they have been having the problem (duration). Take note of when the problem started and how long symptoms have been present.
It is also crucial to note how severe the problem is. For instance, is the shortness of breath preventing the patient from sleeping peacefully?
Are they awaken from sleep because of breathlessness? It is important to take note of the pattern of the problem. Is the problem seasonal or it is present on daily basis?
What are the relieving and aggravating factors?
- patient examination
- use of different forms of tests e.g. spirometry, aterial blood gases, etc
- providing baseline for the patient's progress
- has to follow a standard that can give confidence that nothing has been omitted
Physical or objective examination must start with observation. Observation may help you to take note if the patient is distressed, run short of breath, blue (cyanosed) etc.
...to be continued---