Objective assessment Objective notes

  • cough
    HIV
  • dizzinessnocturnal pain/ drop attacks/
  • coughspeaking/ swallowing problem

  • dizziness
    dizziness
  • coughcancer/ inflammatory arthritis
  • dizziness
    TB
  • cough
    weight loss/ fevers
  • dizziness
    less than 20/ more than 55
  • cough
    double vision
  • cough
    severe pain
  • cough
    spinal cord compression
  • cough
    significant vertebral tenderness
  • cough
    neck trauma/ surgery
  • cough
    preceding trauma or neck surgery

Please seek medical help if any of the above apply or else confirm that you have checked that none do.

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      Health check Before you begin, have you experienced any of the following? If yes, seek doctor as soon as possible. 1: Night sweats? 2: Recent fever? 3: Change in bladder/bowel habits, more specifically urine retention/faecal incontinence? 4: Unexplained weight loss? 5: Cough more than 3 weeks duration +\- blood in sputum? 6: Pain down both legs? 7: Poor controlled leg movement? 8: Loss of feeling down both legs or around buttocks or inner surface of thighs?
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Objective Diagnosis:

collecting point

please make a note the diagnosis number that appears here before clicking the 'next' button (which will take you to your treatment)

Shoulder objective analysis

1 Has there been a recent accident or fall?

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Shoulder objective analysis

Does the patient usually sit with a slouched posture?

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Shoulder objective analysis

Can the patient lift their arm above their head even with pain?

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Shoulder objective analysis

Is there pain in the middle of the movement?

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Shoulder objective analysis

Holding arm out in front, with thumb down, push up against physio’s hands. Is it painful?

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Shoulder objective analysis

Hold arm up at 90° flexion with elbow bent and rotate internally. Is it painful?

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Shoulder objective analysis

Lift arm across body, is it painful?

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Shoulder objective analysis

Is the patient older than 60 years?

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Shoulder objective analysis

Is it painful to touch around the joint, and morning stiffness felt on movement?

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Shoulder objective analysis

Is the patient between 40-55 years and has good strength with resistance tests?

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Shoulder objective analysis

Can the patient move their arm as far as possible, even if painful, without help?

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Shoulder objective analysis

Putting hand behind patient's back, can they lift hand away from body?

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Shoulder objective analysis

Is there a positive external lag test?

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Shoulder objective analysis

Is there a loss of external rotation?

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Shoulder objective analysis

Is there an obvious step down deformity at the edge of the shoulder?

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Shoulder objective analysis

Touching the edge of the shoulder, is it painful to feel corner?

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Shoulder objective analysis

Lift arm across body. Is it painful?

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Shoulder objective analysis

Is the ball of the shoulder joint positioned more to the front of the chest?

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Shoulder objective analysis

Can the patient lift their arm up?

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Shoulder objective analysis

Tap on the bone of the arm away from the site of pain. Is it painful locally and sore when tapped away from site of pain, and bruising present?

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Objective notes alert

Things to observe:

Here, we outline the objective results of your assessment, the progress towards functional goals and any treatments performed. Include details of any interventions, as well as frequency, duration and equipment used. The therapist should indicate changes in the patient's status, as well as communication with colleagues, family or carers.

Try to avoid:

  • Giving no detail
  • Summary detail such as: "ROM exercises given"

essentially, note:

  • range of movement (split into passive and active)
  • muscle strength
  • neurological assessment
  • gait
  • function

Using notes:

Simply type a note and press "Enter" key. You can edit existing notes or delete a note. To delete all your notes, use "Clear". However, as this will remove all notes on this page it is advised to copy and paste them into a document and store them elsewhere before clearing them here.

Shoulder Objective Assessment notes

 

my Objective notes symbol objective

(after listening to my patient's account and from observing all signs and clues given)

  • My observations are...

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(use info button below for guidance)

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