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A Guide to Writing in the Profession of Physical Therapy: Outpatient Clinics

Coming into undergraduate college I was weary on the matter of entering a field heavily involved in the sciences. I never thought I was knowledgeable or skillful on such subject matters in high school and my confidence in being able to handle coursework on such topics was low. However, I had the background of being a dancer since I was three years old and Ive always been very active and interested in how exercise helps and influences the human body. Dancing enabled me to understand how my body moves through first hand experience in ways I never would have comprehended human movement otherwise. With my passion to learn more about human movement and how it is affected by physiology and mechanics of the human body I became thoroughly engaged in my college coursework. To become a one must attend a three year graduate program after getting some sort of bachelorette degree encompassing certain classes. The process used to apply to one of these schools is an online universal application called PTCAS. I just finished the completion of my application and can honestly say I am thrilled to be moving onto one of the final steps in becoming a physical therapist. I now feel confident I will be able to handle a profession in the field of Physical Therapy and was inspired to learn more about the values and goals a professional should encompass to help them thrive in this community. is a wide and growing health care profession that focuses on the rehabilitation of injured or disease-laden individuals of all ages suffering from a large variety of physical mobility issues. Settings of physical therapy range from hospitalized rehabilitative care, to home care, to outpatient therapy settings. This guide will focus on which means these patients have been discharged from a hospital after surgery, have fallen under injury that did not require hospitalization, have age related injuries and pathologies and the list could go on. The main concern of these patients is that they are attempting to get back to the activities of their daily life or at least achieve physical ability levels in proximity of what they used to be able to handle. Patient care is the core with which values and goals of a physical therapist are centered around. Even though education on human anatomy and the therapeutic practices used to rehabilitate and repair mechanical malfunctions are essential to becoming a physical therapist, one will not be successful in the field if they do not have a genuine desire to work with the people and see them improve. Success in the field heavily depends upon being able to produce and work with the writing involved in the profession. One cannot be efficient in dealing with these documents without first understanding the values and goals with which the framework of the writing lies upon. This guide is first going to explore the conventions of a few genres of writing pertinent to the field and then move on to discuss how values and goals of

the community are reflected through them. I will then discuss how credibility and authority of a new physical therapist can be gained in an office with relation to the genres discussed. Finally the guide will cover different roles and identities found in a physical therapy office and the different genres of writing each works with. Primary research done for this guide was done through accessing information from graduate school websites I have applied to, observations Ive made from internships in outpatient clinics and an interview with a current physical therapist, Jen Flynn, from which I will be referring to often throughout the guide.

Genres in a field are classified by the different types of information they hold and functions they serve in the profession. Understanding how to effectively produce and work with genres involved in a community is pertinent to being a functioning member of the workplace. To assist with this there are specific books published and dedicated to physical therapy documentation, one example being Effective Documentation for Physical Therapy Professionals by Eric Shamus and Debra Stern (Flynn). In terms of genres utilized in an outpatient physical therapy office, I will be discussing SOAP notes, initial evaluation forms, and two different types of exercise sheets. : The term SOAP stands for subjective, objective, assessment and plan and encompasses the background, goals and future treatment of a particular patient. Part of these notes can be taken while talking with the patient and some parts are typically written after each patient visit, whether it is right after the appointment or at the end of the day when the physical therapist is done with patient treatment. As I found through my interview with Jen, it is ideal to finish the notes right after the patient has finished their session, but the busy schedule of an office does not always allow for this. Through my internship at Orthopedics and Sports Physical Therapy Association (OSPTA), I noticed the therapist I shadowed tended to write them right after a patient left the office. He would also come into the office early to review his SOAP notes of the patients coming in that day. Recognizing the importance of this genre in relation to helping the patient succeed with treatment is a quality that depicted this therapists desire to want to enhance his patients lives. The subjective part of the notes are based off of what the patient is feeling and the daily living tasks or recreational events they are currently engaging in or having trouble engaging in. The primary purpose of this section is to find out how the patient feels they are functioning. Jen even made a point in the interview that if a therapist can get a patient to talk about their goals and what they want to continue getting out of therapy the better their prognosis will be. The objective section of the notes deals with actual measurements taken by the therapist such as joint angle to determine if range of motion has improved. This allows the therapist to be able to quantify improvements from previous visits. The assessment part of the notes deals with the information the therapist has gathered from the subjective and objective section to produce a framework of how the patient is

improving and depict what is involved with current mobility issues. The plan section of the notes is the treatment the physical therapist will continue with for the patient or is a revised version of treatment plan if previous ones do not seem to be working. Treatment involves proscribing exercises for the patient and therapeutic techniques done hands on by the therapist. Learning how to be effective at writing SOAP notes is taught in graduate school throughout all classes and the more a new physical therapist works with them the better they become at the skill. : The size of the outpatient clinic determines who creates this document for the facility. Large corporations will often have these forms created by supervisors in charge of the business but if a therapist owns their own smaller office they will be the creators of this document. OSPTA was a large physical therapy association so all 25 of their offices utilized the same initial evaluation forms. This documentation is filled out whenever a new patient is to be starting treatment in an office. Initial evaluation forms work to determine the medical history, family history, pathologies and injuries of the patient and allow the therapist to take initial measurements to see the extent at which the patient is immobilized. Forms are pre-created separately for different parts of the body to ease this process for the therapist. : One document pertaining to exercise is exercise sheets that are given to the patient. These sheets depict different rehabilitative exercises the patient is to perform and allow them to better understand how to complete exercises effectively. The facility can create their own sheets but there are also books of exercises already created that a physical therapy office can buy the rights of to be authorized to give them to their patients. This is often preferred because they have nicer pictures and better wording to describe exercises. The print is also created to be a good sized font for the elderly to be able to read (Flynn). Using exercise sheets from pre created documents also allows for the office to spend more time on other aspects of patient care. Another documentation involved with exercise is the exercise sheet the physical therapist creates for employees in the office to utilize so they know what exercises the patient is to be performing during their session. This is often called an exercise chart and is created right after an initial evaluation and exercises are added and revised as the patient continues their time in the office. Throughout my conversations with current physical therapists Ive come to find specific exercises to proscribe patients with are not taught very well explicitly through graduate school. Most therapists find they gain the most knowledge base on this subject through their clinical experiences when they have the ability to gain hands on practice working in the field.

When people are in search of a physical therapist they will often ask for recommendations from others who have experience working in an office or previous patients of a facility. They obviously want to go to the best physical therapy office and be taken care of by skilled physical therapists. However a lot more goes into defining a trustworthy physical therapy office than simply the fact the therapists employed there got accreditation from a graduate school. A truly noble and skillful physical therapist has taken on the challenge of learning latest and most effective therapeutic treatments while acknowledging the ideal none of the their knowledge acquired will be useful without keeping the values and goals of a physical therapist in mind. Physical therapy is a profession for the people and graduate schools ensure their students leave the institution realizing this. The services physical therapists provide are all geared towards improving the lives of their patients and motivating them to continue a new and healthy lifestyle even after their time at the office is complete. Below is a condensed list Ive complied of some main goals and values of physical therapy found from websites of graduate schools Ive applied to, observations Ive made and points from my interview with Jen Flynn. These ideals and goals help to depict what the professional profile of a physical therapist is based off of. : Service learning is a new goal and value I discovered of physical therapy by reading through graduate programs websites. Wheeling Jesuit University really takes pride in their programs implication in teaching this goal and the ideals of it to their students, as a whole section was dedicated to this area on their website. According to Wheeling Jesuit service learning prepares physical therapists for ethical leadership, the betterment of society and service to others, including areas underserved by the health care system (Service Learning). Service learning educates physical therapists on patients whom have trouble accessing physical therapy through their health care situations due to their socioeconomic status. Being exposed to patients in these situations allows for the therapist to be able to reflect upon their values that they have a civic responsibility to the public (Service Learning). This allows for personal growth of the physical therapist as an individual involved in the health care system. A few examples of how Wheeling Jesuit allows their students to be exposed to patients in tough situations are by having them provide physical therapy at free local clinics, exercise instruction to patients at dialysis clinics, and even have them venture to places like South America (Service Learning). This allows for observations of the disturbances of other cultures to be seen and open up service learning to a global level. Ive experienced the idea of service learning at my internship with OSPTA by observing a policy they have related to pay of services. When a patient comes in for a session, depending on their insurance, they will normally have a copay. This means they pay a fee at the beginning of their session when they come into the office. At OSPTA, if a patient states they are financially unable to handle this charge the office will take care of it for them. This exemplifies how the OSPTA office recognizes the value of service in caring for patients in financial crises.

: It is advocated during graduate schooling and after graduate school that physical therapists continue to be educated on new medical bases for treatment. Therapists are not adhering to their value of providing the most effective therapeutic practices to the people if they are performing outdated services. Performance of outdated techniques could lead to further injury or a lack of improvement in patient mobility. Through my internships and interview I found to execute the practice of maintaining and learning knew knowledge physical therapists are required to continue to make educational goals for themselves by attending seminars dedicated to new treatment findings from research. This encompasses the value of lifelong learning in that therapists are required to keep up with new procedures for the duration of their career as a physical therapist (Slippery Rock Program Overview). Therapists can continue to make their own personal goals as well by taking extra college classes if they take some time off to stay fresh on their knowledge or they can become further specialized in different areas of therapy. Jen Flynn reported that when she took a leave of absence she enrolled in college courses to enable herself to keep practicing the use of knowledge in relation to patient functioning. The physical therapist I interned for was taking classes at the time of my internship to become further specialized in vestibular activity which means he was gaining more knowledge on how balance relates to function of mobility. It is also encouraged physical therapists join an organization called the American Physical Therapy Association. This allows them to be consistently informed on new research developing in the field. Members of this organization benefit because they get extra continued education and receive monthly educational magazines that serve as a good reference for treatment. The only con of joining this organization is that it is a little pricey being 600 dollars per year to become and remain a member (Flynn). : It is important that physical therapists do not provide a type of treatment to a patient with which he/she is not comfortable. Part of Slippery Rock Universitys philosophy is We also believe that all patients must provide informed consent and are empowered through education and intervention to manage their condition (Program Overview). One of the main values and goal of a physical therapist is to ensure their patients are being encouraged to improve their mobile conditions and motivate them to want to continue improvements after their time spent at the office is complete. However in order for a physical therapist to ethically execute such treatment plan they must ensure they are informing the patient of their condition and the treatments being used to rehabilitate them. This is to ensure the patient is not left out in the dark about what is happening to their body. HIPPA is a policy implemented through insurance companies that entails physical therapists to be sensitive with patients medical information in that theyre personal profiles are not being shared with eyes unrelated to improving their medical condition (Flynn). Through my interview and internship I also found it is unethical of a physical therapist to continue treatment of a patient who can no longer benefit from the therapeutic practice. This means after therapy has done all it can do it is now up to

the patient to tailor their lives best suited to their situation, the therapist should discharge them from treatment. : It is encouraged for physical therapists to get involved in research because it enhances their knowledge base on human anatomy and therapeutic practices related to it. However it is essential one must be careful to respect the human body and not cause bodily harm to an individual in order to gain a benefit of knowledge (Slippery Rock Program Overview). All of these values and goals demonstrated by a profound physical therapist allow them to better produce the documentation essential for patient care. For example, Jen stated a good physical therapist will ask themselves questions while writing SOAP notes. Is the patient improving their walking pattern? Did I effectively implement treatment for a new hip replacement? Is an elderly individuals quality of life improving as best as it can? Questions such as this reflect upon how a therapist is constantly referring back to the roots of what they should be paying attention to regarding patient care and treatment. When I asked Jen if she felt the effectiveness of the creation of SOAP notes, initial evaluation forms and exercise sheets reflected the capability of a physical therapist to treat a patient she replied that it absolutely does. For example when utilizing the objective section of SOAP notes or performing an initial evaluation, a therapist is implementing their physical skills of being able to assess quantifiable variables of patient mobility and perform palpations of the human body. This requires the physical therapist be kept up to date and freshened on their education of human anatomy and the important factors influencing it when referring to treatment plans.

Beginning a career in a new work place can be a scary and challenging obstacle in a beginner professionals life. Graduate school for physical therapy should have given students the appropriate knowledge basis needed to be successful in the office and clinical experiences throughout graduate school should have given them quality exposure to the outpatient therapeutic setting. However no matter how much practice and experience one gains it seems like a whole new ball game when a physical therapist receives their first patients to rehabilitate. I felt as if I got to experience this phenomenon when I was given my first patient as an intern to help them with their exercises. I was apprehensive I would give them the wrong instructions or cause them to fall, but I knew I had the background knowledge behind me to help me meet my first goals of becoming a trusted professional. I also felt I had gained respect from other employees in the office which boosted my confidence I would be able to handle this challenge. From my interview with Jen, I was able to come up with a few practices a new physical therapist could engage in to

gain credibility in their new office and become an authoritative employee with the confidence to be able to treat their patients with the best care. : Physical therapists who have obtained a supervising position perform weekly or monthly performance reviews on other physical therapists in the office. A few elements performance reviews evaluate are: 1. The therapist is writing neat SOAP notes that meet the standards of quality insurance companies wish to see so the office will get reimbursed for their services. 2. The therapist is writing clear initial evaluations for each new patient with all pertinent information clarified. 3. The therapist is handling patients with ethical care and respecting HIPPA policies. 4. Therapists are using the latest and most effective practices for their patients and are not settling for second best. Even though new employees may feel they are under pressure being at the hands of more experienced physical therapists, this does not mean they should try and act superior to anybody else. New employees and all physical therapists under their supervisor should treat those in charge with respect and adhere to office policies. This shows the employee also respects the ideals and values of a physical therapist in that patient care is the most important goal of an office. Physical therapists whom practice good companionship to others in the office will receive more respect back in return. : It is an acceptable practice as a new physical therapist for them to continue shadowing other employees at the office until they feel they understand all the reins. This includes: 1. Observing how they handle patients. 2. Observing treatments and exercises they proscribe to patients. 3. Reviewing their SOAP notes and initial evaluation forms. This enables the new physical therapist to get a grasp on how other employees successfully handle situations around the office. It also shows to other employees the new physical therapist is genuinely concerned about the conventions of the office and has a drive to become a successful and contributing employee to

the community. This puts the therapist at a more respectable position in the eyes of other therapists and shows they know how to take authoritative steps. : Ive experienced firsthand how busy and intimidating an office can be right after lunch hours when patients are coming in by the dozen. Patients often show up late or perform their exercises slowly which backs up the office schedule even further. It is essential to come to terms with the fact that as a physical therapist there will be days when one works for twelve hours with a twenty minute lunch break. It is pertinent the new physical therapist does not let their first days experiencing this phenomenon discourage them. If they work to keep in mind the ideals and values they have gained throughout their experience thus far they will be able to work under pressure and remember their love for the profession. It is essential to keep up a personable presence around patients in the office at all times so they will trust their care in the hands of the therapist. This allows other employees of the office to see the new therapist is working to maintain the communitys reputation. : SOAP notes, initial evaluation forms and exercise sheets and charts are essential to maintain the credibility of an outpatient physical therapy office. The more a new physical therapist demonstrates understanding of the importance of documentation the more their work will be respected by other therapists of the office. Along with respect for their work comes respect for their character as a functioning member of the community and other employees will learn to trust them with their own patients as well. Some ways to take initiative with documentation are: 1. Review all patients SOAP notes at the end of the day. 2. Double check to make sure SOAP notes and initial evaluation forms are meeting all standards for insurance reimbursement (conventions described in the genre section of the guide). 3. Get patients to talk about their condition in a subjective manner so the therapist knows more on how they feel about therapy. 4. If taking off a day of work, have another therapist take over writing their patients SOAP notes. 5. Proscribe patient exercises right after completion of an initial evaluation. 6. Talk with each patient to make sure exercise proscribed is working for their condition and that they understand how to complete them. 7. Ensure all patients are taking home exercise sheets to continue their therapy outside the office

By taking steps to show the new physical therapist is attempting to go above and beyond office standards of work they will be seen as an essential asset to the community.

There is a system of rankings within an outpatient physical therapy office that work to create a functioning unit in which each part of the unit deals with specific elements of the office. While different rankings of employees in the office have their own set of tasks to complete, they all have the same identity when it comes to dealing with patients. This goes hand in hand with the fact taking care of the patient is the primary concern of the entire office, so different rankings of employees must all come together for this common goal. It is necessary for all employees to collaborate their work because: 1. Everyone in the office needs to be on the same page in terms of patients visiting and documentation being processed for each one. 2. Most of the time employees with different roles in the office all work directly with patients to help them complete their exercises. 3. It is necessary for employees to work as a team to help a busy schedule run as smoothly as possible and keep patients flowing through their routines. Presented here is a list of different roles in the office from the highest ranking employee to the lowest. While they all take on the common identity of being a provider to the patient, each position also delves its own identity with respect to specific elements of patient care and documentation involved in it. : Every physical therapist in the office has their set of patients. Even though the physical therapist supervisor has their special tasks as well, this also includes them. Just because a patient is listed under one physical therapists name does not mean other physical therapists in the office cannot perform procedures on them. Patients, however, normally prefer to be seen by the therapist they have been working with. As far as specialized tasks go on top of performing procedures on their patients, physical therapist supervisors are the ones to conduct performance reviews on other therapists. It is their job to foresee all standards of the office are being met through documentation purposes to ensure insurance reimbursement and that patients are receiving the utmost care. Physical therapist supervisors will often be the ones to write letters to clinicians sending patients to the office. Letters can be written in situations involving patient medication or confusion as to what the doctor recommended as the patients treatment (Flynn). Becoming a supervisor can be achieved through having years of experience working in an office and does not require a higher degree than a normal physical therapist.

: Physical therapists encompass all the roles of a physical therapist supervisor minus conducting performance reviews and have slight lack of authority compared to the supervising role. Presented is a basic and condensed list of tasks required of a physical therapist: 1. Read patients doctors scripts so they can get an idea of the patients condition, any medications involved, or request for a specific treatment. 2. Perform initial evaluations on new patients. 3. Proscribe exercises related to patients condition and continuously revise exercise and treatment plan. 4. Perform manipulations, palpations and massages related to patients condition. 5. Keep patient SOAP notes up to date and organized. Physical therapists maintain an identity to the patient as being their primary care provider throughout their experience in the office. While all other employees will also work with patients in some form or another, the physical therapist is seen as the person the patient will desire to have the most trust for and rely on most heavily. : Becoming a physical therapist assistant requires a two year program after earning a bachelorettes degree, but is not considered a doctoral degree. PTAs are limited to the manipulations and joint mobilizations they can perform, do not write their own set of SOAP notes for patients and are not permitted to proscribe treatment procedures. However PTAS are critical to the outpatient environment in that they have a major role in making sure the office procedures are running smoothly and ensure all patients are receiving attention while in the office. Even though they do not have their own set of patients, through my internships I have observed PTAs are constantly working with patients to help them improve their conditions and get through exercises in the appropriate manner. Because of constant contact with the patients, the patients really look up and trust the PTAS to provide them with care. They often formed as close of relationships with the patients as the physical therapist themselves do because their identity in the office is still marked by credibility and the desire to perform patient care. : A physical therapist technician is often times, but not always, college students who want to have a part time job earning experience in the field they someday wish to become a professional in. However, they are limited on the services they are able to provide due to insurance liabilities. Physical therapist technicians have not yet completed a graduate school program which puts patients and themselves at a higher risk of injury if they were to attempt tasks they

are unqualified in such as joint manipulations. The technician role however is highly respected throughout the office in that they provide substantial assistant to higher rankings of physical therapists. They work with patients to help them complete their exercises and make sure they are producing motions in a manner effective to rehabilitate their condition. In terms of documentation they are responsible for keeping track of patients exercise charts while they are in the office and checking off each exercise after the patient completes it. This position is a great way for aspiring physical therapists to gain hands on and direct access to the communitys values, goals and functional aspects of the office.

Flynn, Jen. Personal interview. 28 Oct. 2013. Phone. Slippery Rock University. Program Overview. Retrieved from http://www.sru.edu/academics/colleges/ches/pt/Pages/PTProgramOvervi ew.aspx Wheeling Jesuit University. Service learning. Retrieved from http://www.wju.edu/academics/dpt/servicelearning.asp

Research/Interview Questions & Answers: Genres Do you feel there is any other important documentation involved in physical therapy besides SOAP notes, initial evaluation forms and exercise documentation? insurance documents? discharge forms? Progress notes, every visit or at least once a week. summary of treatment, some facilities every visit some every week, can be in SOAP note format Exercise Documents Do physical therapists create their own exercise sheets they give to patients to take home to help them remember how to complete them correctly? facility creates them, books of them are already created and you can by rights, have nicer pictures and better wording can customize, more time efficient already available to you elderly may have sight problems I've heard graduate school does not prepare you with a bank of exercises to proscribe patients with. How would you say most physical therapists go about learning what the most effective exercises are to induce rehabilitation? You learn a lot on clinicals during graduate school, learn from being mentored, learn basics at school then learn to apply it during clinicals, at pitt in clinic for whole 12 months I've observed physical therapists need to proscribe new exercises to a new patient quickly after an initial evaluation is complete. Is this a difficult skill to become efficient in? yes, you start patients out with minimal amount of exercises though which makes it easier SOAP Notes What do you feel are the main or most important elements of SOAP notes? if patient can talk about goals, very important why in pt what do want to get out of it Is time efficiency also a factor in creating this document? its ideal to write them as you go along Were you taught about SOAP notes specifically in grad school? yes it was incorporated, theres specific books on it dedicated to phys therapy documentation Initial Evaluation Forms What are the most important elements to consider when performing initial evaluations and creating that form? all equally important (like SOAP notes) Who creates the initial evaluation forms for the office? depends if you work for big corporation or have own office, then make own Are certain initial evaluation forms more difficult to complete and interpret regarding different parts of the body? no not really, whole forms dedicated to one thing already provided

Community Goals and Values -Main values and goals of the physical therapy community as a whole What are the three main values you would say a physical therapist feels are most important? culture and diversity, HIPPA (be sensitive with information), look on website slippery rock, treat people appropriately, some offices cut bills for patients, make sure you discharge patients if theyre getting better, dont overbill Regarding these values, what are three main goals of a physical therapist with regards to patient treatment and care? focus on short term and long term goals of patients pt goals: PA makes you continue education goals to keep up on procedures, lifelong learning, home health phys therapy even if not working take courses Do you feel when you were in graduate school these goals and values were taught explicitly by professors? encourage to be a member of APTA , provide continued education magazines, but it is expensive (600 a year) Did you consider you're own values and goals of what it means to be a physical therapist before you started your career? Would you say most physical therapist take the values and goals of the physical therapy community to heart? In regards toward SOAP notes and initial evaluation forms, do you feel these values and goals are reflected throughout the creation of these documents? -is patient improving, did I effectively make this person better, improve quality of life? return home? In your opinion, how seriously do you feel physical therapists take these documents? Some more seriously than others? Do you think the effectiveness of the creation on these documents reflects the capability of the physical therapist to treat a patient? yes absolutely, objective parts of SOAP notes are YOUR testing and this requries skill, palpations, know what to look for skin red open cut balance testing skills of patient more at risk to fall or not Authority/Credibility What are the most important factors of an office you would say a new physical therapist should pay the most attention to in regards to social structure? What about in regards to patient care? showing respect to someone who has experience, learn from other therapists and watch when theyre treating patients, how they document, shadowing is appropriate Is the creation of SOAP notes and initial evaluation forms generally a challenge for new physical therapists? How do they improve? now a lot of stuff is predone compared to past years, this is thought by some to take away creativity Are new physical therapists judged by older professionals upon their creation of these documents? older PTs do check to make sure pts are writing soap note efficiently, keep chart notes for performance reviews on all pts to make sure one is meeting appropriate

things, reimbursement for insurance standards are met, if someone takes leave find someone to take over notes Roles or Identities What professionals in the physical therapy office are ranked above the physical therapist? Do they have specialized documentation they must complete? enjoy having students underneath you to be a mentor, mentor pt assisstants and technicians supervisors are ranked higher than pts, does performance reviews writes letters to physicians, its hard to get used to reading handles many doctors leave treatment up to physcial therapists, include diagnosis What about physical therapy assistants? Are they involved at all in the creation of SOAP note? Initial evaluation forms? What writing are they involved in? pt assisstants do SOAP notes but cant do initial evaluations, can do goiniometry girth measurements but cant be official about it pt must do assessment and plan In regards to physical therapist technicians would you say they have any important roles in the writing process? Possibly with regards to patient exercise sheets? deal with reps done by patient, in state of PA extremely limited what can do I know many offices have secretaries, what documentation are they mainly involved with? insurance documents Do employees of different roles ever work together when dealing with these documentations? when create forms people give opinions on what they think should be on it