Note: document all (+) 1st before sig. (-) findings.

If palpation will trigger 5x in

pt., perform this test last during the evaluation.
ROM:
Motions of (B) UE/LE, neck and trunk were assessed actively, pain-free ad are
WNL except for the ff: (if there are maximum of 5 joints with LOM)
OR
Active ROM of (B) UE/LE, head and trunk revealed findings that are WNL and
pain-free. The ff. joints were assessed passively with the ff. findings:
Sig: (take note of lecture on selective tissue tension testing)

LOM 2

to pain on {(B) active and passive maybe limited}

LOM 2

to contracture {(B) active and passive maybe limited}

LOM 2

to tightness (usually active is limited but passive is normal or

nearly (N)

LOM 2

to weakness (active is limited, passive is (N)

MMT
Resisted isometric testing revealed grade of ____ (5/5 or 4/5) for the ms of (B)
UE/LE head and trunk. (If with weakness, continue with..) except for the ff. ms
wherein standard MMT was used.
Muscle Grade
OR
All major muscles of (B) UE/LE were grossly graded ___ (5/5 or 4/5 etc)
Note:
- Break test was used
- Resisted Isometric Testing
Note: If you see these two for pain or contracture, no need to document
using RANGE Grade
In cases of contraction or pain, using MMT will require documentation of
range grade
Note: available range/grd of ms.
For SCI, may use ASIA chart to document ms strength
For UMNL, use FMT instead of MMT as heading (or in cases of extreme/severe
pain)
Use NWB functional act. for (B) UE
Use NWB functional act. for B (LE) (or upright motor control test for LE)
Use functional activities for trunk; reaching, lateral flexion, supine, prone
For children, use Pedia MMT or FMT

Sig: ms weakness 2
-

to

Inactivity
Immobilization
Disuse
Denervation
Tendon/ms rupture

SPECIAL TESTS
Use only those that will confirm the diagnosis and are sig. to the case. It is
not our duty to rule out diagnosis; can only be used to confirm a difficult
diagnosis
Significance: Give significance for each test that you have used
Every test has a corresponding significance or use.
NUERO EVALUATION
Sensory Testing
If not neuro cases, separate testing or only if necessary
Superficial sensation:
- Note for STDs used (pin prick for pain, brush for light touch and thumb for
pressure)
- Pt. has intact sensation as to pain, light touch and pressure
- Pt.as ____ % sensory deficit as to ________ (sensation) on where
- For affectation of peripheral or cutaneous innervations, test isolated area
supplied by the nerve
- Documentation for dermatomal/cutaneous distribution, testing, may draw
past tested & or isolated distribution of nerve.
Significance:
-

Hyperesthesia/hypoesthesia 2

to:

Affection? ________ nerve

________ dermatome
Broddman area 3,2,1
Thalamus
ALTS

Hyperesthesia 2

Note whether distal or proximal part of body has been assessed.

to pain

Deep Sensation
- Assess for movement and position sense
- Intact proprioception on (B) UE/LE
- Note that this is tested using distal body parts.
Cortical Sensation
- Perform stereognosis (if cannot manipulate with hands, use
graphesthesia)
- Tactile localization, 2-pt. discrimination, Bilateral simultaneous stimulation
- You can use the ff. terms: Intact, Decreased, Exaggerate, Inaccurate,
Absent, Inconsistent, Ambiguous

MSRs
For neuro case, for ortho case with affection of nerve roots or peripheral
innervations
Give first findings- e.g pt. is normoreflexive
Sig: intact reflex arc (or what is appropriate)
Tone Assessment
Use terms: hypo-, hyper-, normo-tonic and the laterality and limb tested
e.g. (+) gr. 1 spasticity on (B) LE (Ashworth Scale)

Sig. spasticity 2
Rigidity 2
Dystonia 2

to _____
to _______
to _______

Paratonia 2

to _______

Flaccidity 2

to _______

Clinical Rating Scale used to assess tone:

0- No response (flaccidity)
1+ Decreased response (hypotonial)
2+ Normal response
3+ Exaggerated response (mild to moderate hypertonia)
4+ Sustained responses (severe hypertonia)
ASHWORTH SCALE for Spacticity Grading
Cranial Nerve Testing
CN
I
II
III, IV, VI
V
VII
VIII
IX, X
XI
XII

Result of Test
Pt. can smell
Intact light reflex
Intact conjugate eye movement
Intact corneal reflex/facial expression
Functional ms. of facial expression
Pt. can hear
Intact gag reflex
Normal trapezius/ SCM strength
Pt. has (N) articulation

Sif: of affected, usually signifies brainstem affection or individual cranial nerve is

affected, may manifest as central or peripheral lesion
Phatological Reflexes
e.g (+) clonus on (R) LE
sig. hyperactive stretch reflexes
(+) Babinski (some book suggest a (+) or (-) extensor plantar response instead
of Babinski

sig. corticospinal tract affectation or UMNL lesion

Developmental Reflexes
Test 4 levels of reflex development
e.g (-) grasp reflex on (B) feet and hands
(+) protective extension in sitting
Sig. Pt. is in brainstem level of reflex development
Coordination Testing
Non-Equilibrium
*Select test appropriate for pt. & case
Equilibrium
Legend for grading:
4
3
2

normal performance
movement accomplished with slight difficulty
moderate difficulty, movt, arrhythmic performance, deteriorates
with inc. speed
sever difficulty, very arrhythmic, unsteady, oscillations, extrenous
movt
unable to accomplish task

1
0

ANTHROPOMETRIC MEASUREMENT
Leg Length Measurement
Sig. TTL discrepancy 2
ALL discrepancy 2

to bone shortening
to pelvic obliquity, contracture

Muscle Bulk Measurement

Sig. atrophy 2

to denervation, disuse

*For atrophy of hands/feet, use volumetric measurement

Limb Girth Measurement

For atrophy of limbs
Sig. edema
Swelling

POSTURAL ASSESSMENT
Take in _____ view (choose best view that will show deviation)
e.g taken in standing position, ant view
- head in midline

shoulder level
equal carrying angle
ASIS level
knees level
malleoli level
lateral view
- head forward
- shoulders rounded
- increased thoracic kyphosis
- flattened lumbar lordosis
- hips slightly flexed
- knees slightly flexed
sig. compensatory posture to facilitate breathing
GAIT ASSESSMENT
Rancho Los Amigos
Note: data correlates the amt of motion taking place a joint with that of (N) values
(note flexion, extension, etc)
- Stance phase time- ______ & laterality
- Swing phase time- ______ & laterality
- Trunk rotation: arm swing
- Cadence
- Step length, stride length
Sig. type of gait that pt. exhibits
FUNCTIONAL ASSESSMENT
FIM LEVELS
No Helper
7- Complete independence
6- Modified independence
Helper-Modified dependence
5- Supervision (subject 100%)
4- Min. asst (75%)
3- Mod. Asst (50%)
Helper-Complete dependence
2- Max. Asst (25%)
1- Total Asst or not testable (less than 25%)
Wound Assessment
- Shape
- Size
- Depth
- Odor
- Color-scar, granulation tissue
- If pressure sore, note the grade
Pressure Sore Grading

GRADE 1: Discolouration of intact skin not affected by light finger pressure (nonblanching erythema). This may be difficult to identify in darkly pigmented skin
GRADE 2: Partial-thickness skin loss or damage involving epidermis and/or dermis.
GRADE 3: Full thickness skin loss involving damage of subcutaneous tissue but not
extending to the underlying fascia.
The pressure ulcer presents clinically as a deep crater with or without undermining
of adjacent tissue.
GRADE 4: Full thickness skin loss with extensive destruction and necrosis extending
to underlying tissue.
STUMP
-

ASSESSMENT
Shape, length, type, calculate % of stump to classify
Type of closure used (fish mouth or post flap)
Is skin mobile or adherent tissues
Presence of neuroma

ELECTRODIAGNOSIS (for PNI)

- Perform SDC or other tests (impression will be given on A part of the note)
- For cardiac cases, please include assessment & endurance testing.
ASSESSMENT
DIAGNOSIS:
PT IMPRESSION/REHAB POTENTIAL
Based on Objective Findings
Functional Limitations
e.g stage 3-Bobath Stages of Recovery
Note: short, measurable, accurate, realistic, time bound
Plan
Pt. will be seen _____x/week for _____ tx sessions
- Enumerate Mx given
*Modifies first before exercises
*GIVE COMPLETE PARAMETERS FOR EACH
- Home/Ward Instructions
- Suggested Mx
- PT instructions to pt. e.g energy conservation technique, proper body
mechanics
Swelling
Comes on soon after injury blood
Comes on after 8 to 24 hours synovial
Boggy, spongy feeling synovial
Harder, tense feeling with warmth blood
Tough, dry callus
Leathery thickening chronic

Soft, fluctuating acute

Hard bone
Thick, slow-moving pitting edema

Cramping, dull, aching

Dull, aching
Sharp, shooting
Sharp, bright, lightning-like
Burning, pressure-like, stinging,
aching
Deep, nagging, dull
Sharp, severe, intolerable
Throbbing, diffuse

Muscle
Ligament, joint capsule
Nerve root
Nerve
Sympathetic nerve
Bone
Fracture
Vasculature