I sparingly get previous records (SOAP notes, flow sheets, etc.) of current patients that may have been referred to our office from other physical therapy locations, but it does happen. A recent example involved a young female who is home from college who was receiving PT at school for status-post shoulder surgery (she is an athlete and needs to continue PT). Most of the time, its boring notes!; but one thing I do notice is how ‘easy’ I can get an idea of where the ‘patient has been’ in rehabilitation by following the flow sheet exercises and dates. I know where she started, how she progressed and a good idea where I should go from here; all without even evaluating her. This is due to the common and universal understood language between physical therapists concerning therapeutic exercise. Yes, there are different descriptions for exercises at any clinic, but for the most part, the nomenclature is quite accurate and consistent across the board. I found it was a smooth transition for the young athlete and it is comforting to know that intraprofessional referral can be rewarding. However, what if the patient was referred intra-professionally while on vacation to our nearby lake or a second home? Will this be the same if the patient was referred from a manual therapist who focused on passive, pain-relieving techniques and not all exercise? Would I have trouble knowing what they did and be able to replicate it accurately and applied appropriately?
To address this, AAOMPT in 2007 created a task force to standardize terminology in manipulative techniques. You can get the whole article here (subscription required). I am sure it was a daunting task, but the following is the proposed framework:
In clinical sense, an example provided by the authors is:
“a high-velocity, end-range, right-rotational force to the lower lumbar spine on the upper lumbar spine in a right side-lying, left lower thoracic lumbar side-bent position”
More specific, yes, and simplified for the next clinician, yes. However, biggest question is where will all this fit on the flow sheet?!
I may write something more simpler to the extent of “T4-9 supine HVLAT”. Is this good enough or still gibberish?
Either way, this shows our need to communicate more directly with professionals in our own field, but also inter-professionally too. It would help with a smoother transition of plan of care and bring us together as a unit for more consistent results.
What are your thoughts? How do you communicate in your notes? And, if you ever refer out to other professionals or been referred to, do you find the language is specific enough?