AUDIT REPORT T2.1 PHYSICAL THERAPY EVALUATION

question 4

Short Answer

AUDIT REPORT T2.1 PHYSICAL THERAPY EVALUATION
The following is an initial physical therapy evaluation for which you are to report Mary Barneswell's service.
SUBJECTIVE: Michelle is a female patient seen in Hand Therapy on direct referral from Dr. Ronald Green with the above diagnosis. This is a patient that was diagnosed with breast cancer a year ago. She currently is undergoing active chemotherapy treatments. She had surgery a year ago and had no edema until the past month. She is also complaining of some shoulder discomfort in the right.
OBJECTIVE: The patient presents today with a right upper extremity that has some areas of red, blotchy skin with some slight increase in edema through the entire arm. Patient indicates that at times the red areas in her arm are fairly bright red and inflamed looking. She notes that the swelling is somewhat down today compared to other days.
Circumferential measurements taken today are as follows: On the right, the metacarpals are 20 cm, wrist 17.5 cm, 9 cm above the wrist 21.3 cm, 16 cm above the wrist 23.7 cm, elbow 27 cm, 12 cm above the elbow 33 cm, and axilla 35 cm. On the left, the metacarpals 18.5 cm, wrist 17 cm, 9 cm above the wrist 19.8 cm, 16 cm above the wrist 23 cm, elbow 25.2 cm, 12 cm above the elbow 30.2, and axilla 35 cm.
The patient has not had any hand or thumb swelling to speak of, and fingers look comparable to the noninvolved left side. She has no numbness or tingling but does complain of some shoulder discomfort. Active range of motion in the right upper extremity is full, with exception of end ranges of shoulder motion lacking 20 for flexion and extension.
DIRECT TREATMENT: The patient is seen today primarily for the fitting of a sleeve per physician's orders. Today we fitted her with an over-the-counter size VI Juzo sleeve. Fit was fairly good today. The patient was instructed to wear this sleeve during daytime activities and to remove it overnight. She is able to independently apply it. She was also sent with a tube of roll-on grip to utilize on her skin to help hold the sleeve in a good position on her arm. We then reviewed some gentle massage techniques focusing on moving the fluid up, out of the arm and towards the shoulder area. The patient was able to understand these and could complete these a couple times per day. We also reviewed some general lymphedema precautions as well as skin care.
ASSESSMENT: Lymphedema and arm swelling.
PLAN: This patient is not in need of direct ongoing care. I am hopeful that with the use of her over-the-counter sleeve, her swelling will be well controlled. The patient's long-term goals are to achieve maintenance of decrease in the swelling in her arm and be able to use her arm unrestricted for all tasks. Short-term goals include pain-free use of her arm for all activities, including use of her crutch at home, no increase in swelling during the daytime with the use of the sleeve, continued assessment of the edema and the skin condition with progression to a more active massage program or bandaging if the need arises.
The patient was given a phone number and a card and instructed to phone us if things flare or if she is not doing well with the use of her sleeve.
T2.1:
SERVICE CODE(S): 97162____________________________________________
ICD-10-CM DX CODE(S): I97.2________________________________________
INCORRECT/MISSING CODE(S): _____________________________________

---

Definitions:

Punishment

The application of an aversive stimulus following a response in an effort to decrease the likelihood that the response will recur.

Positive Reinforcement

A method in behavioral psychology where the introduction of a rewarding stimulus following a desired behavior increases the likelihood of its recurrence.

Operant-Conditioning

A method of learning in which behavior strength is altered via rewards or penalties.

Skinner Box

A controlled environment used to study animal behavior, named after B.F. Skinner, an American psychologist.