From the Guidelines
A comprehensive rehabilitation and physical medicine history and examination report should include several key components, prioritizing the patient's understanding of their diagnosis, duration and progression of symptoms, and goals and priorities with rehabilitation, as outlined in the most recent study 1. The report should begin with the patient's demographic information, chief complaint, and history of present illness, detailing the onset, duration, and progression of symptoms.
- Document past medical history, surgical history, medications, allergies, and social history including occupation, living situation, and functional status before the current condition.
- The review of systems should focus on neurological, musculoskeletal, cardiovascular, and respiratory systems.
- The physical examination should include vital signs, general appearance, and detailed assessments of the affected body regions with special attention to range of motion, strength, sensation, reflexes, coordination, gait, and functional abilities.
- Pain should be evaluated using standardized scales, noting location, quality, intensity, and aggravating/alleviating factors.
- Include relevant diagnostic test results such as imaging studies, electrodiagnostic tests, or laboratory findings. The most recent study 1 emphasizes the importance of understanding the patient's diagnosis and goals, while other studies 1 provide additional guidance on the components of a comprehensive rehabilitation and physical medicine history and examination report. However, the highest quality and most recent study 1 takes precedence in guiding the recommendation for a comprehensive report. The key components of the report should be guided by the most recent and highest quality evidence, prioritizing the patient's understanding of their diagnosis and goals, as well as their functional limitations and rehabilitation potential 1.
From the Research
Full Rehabilitation and Physical Medicine History and Examination Report
The process of taking a patient's history is a crucial aspect of rehabilitation and physical medicine. According to 2, preparing the environment, communication skills, and the importance of order are essential components of taking a comprehensive history.
Importance of History Taking
- History taking is a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment 3.
- Important communication skills for nurses when history taking include active listening, empathetic communication, and cultural sensitivity 3.
- By actively engaging the patient in a conversation about their health issues, the nurse facilitates their participation and autonomy 3.
Neuroplasticity in Musculoskeletal Rehabilitation
- Evidence is emerging for central nervous system (CNS) changes in the presence of musculoskeletal dysfunction and pain 4.
- Motor control exercises, and potentially manual therapy, can induce changes in the CNS, yet the focus in musculoskeletal physiotherapy practice is conventionally on movement impairments with less consideration of intervention-induced neuroplastic changes 4.
Comprehensive Health History
- Taking a comprehensive health history is a core competency of the advanced nursing role 5.
- The purpose of the health history is to source important and intimate knowledge about the patient and allow the nurse and patient to establish a therapeutic relationship 5.
- Reflective practice, a core value of nursing, means learning from experience, and can be used to enhance clinical practice 5.
Exercise as Medicine
- Exercise can be prescribed as therapy in 26 different chronic diseases, including musculo-skeletal disorders such as osteoarthritis, osteoporosis, back pain, and rheumatoid arthritis 6.
- The effect of exercise therapy on disease pathogenesis and symptoms are given, and the possible mechanisms of action are discussed 6.