Clinical History in Physical Medicine and Rehabilitation: An Element for Functionality
DOI:
https://doi.org/10.25759/spmfr.276Keywords:
Medical History Taking, Physical and Rehabilitation MedicineAbstract
Aim: To present a conceptual model of clinical report in Physical and Rehabilitation Medicine, based on its role of promoting physical and cognitive functionality.
Material and Methods: A review of the literature was performed, starting with a search in the PubMed database and consulting additional sources of information.
Results: We observed that the content of the clinical report is relatively consensual among authors, but the structure to which it obeys is not homogeneously described. In this paper we present a model of clinical report based on the literature analyzed.
Conclusion: The clinical report is a key element in the assessment of any patient. Although there is a common structure, the particularities of each specialty require an adaptation of this model, in order to guide the collection of data for its specific objectives. In the case of Physical and Rehabilitation Medicine specialty, the functional and contextual assessment of the patient is of particular importance, since it is determinant for the establishment of the rehabilitation strategy.
Downloads
References
Gutenbrunner C, Ward AB, Chamberlain MA, editors. White book on Physical and Rehabilitation Medicine in Europe. J Rehabil Med. 2007; 45 Suppl: 6-47.
Pinheiro JP. Medicina Física e Reabilitação/ Rehabilitation Medicine. [consultado 2017 Nov 30]. Disponível em: http://mfr-fmed-uc.blogspot.com
Weiss LD, Weiss JM, Pobre T. Oxford American Handbook of Physical Medicine and Rehabilitation. New York: Oxford University Press; 2010.
Rondinelli RD, editor. Guides to the Evaluation of Permanent Impairment. 6th ed. Philadelphia: American Medical Association; 2008.
Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther. 2002; 82: 1098-107.
Rauch A, Cieza A, Stucki G. How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Eur J Phys Rehabil Med. 2008; 44: 329-42.
Emedicine.medscape.com. New York: Medscape, LLC. Adult Physiatric History and Examination: Introduction and overview. [consultado a 2017 Dez 5]. Disponível em: https://emedicine.medscape.com/article/317515-overview
Emedicine.medscape.com. New York: Medscape, LLC. History and Mental Status Examination. [consultado a 2017 Dez 5]. Disponível em: https://emedicine.medscape.com/article/293402-overview
Bickley LS, editor. Bates’ Guide to Physical Examination and History Taking. 9th ed.New York: Lippincott Williams & Williams; 2007.
Monahan FD, editor. Mosby’s Expert Physical Exam Handbook. 3rd ed. Berlin: Mosby Elsevier; 2009.
Kaelin DL, editor. Braddom’s Physical Medicine and Rehabilitation. 5th ed. Philadelphia: Elsevier ; 2016.
Harrast MA. Clinical Practice of Physical Medicine & Rehabilitation. Washington: University of Washington, School of Medicine; 2005. 13-31.
Frontera WR, editor. DeLisa’s Physical Medicine and Rehabilitation: Principles and Practice. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2010.
Araújo F, Pais Ribeiro J, Oliveira A, Pinto C, Martins T. Validação da escala de Lawton e Brody numa amostra de idosos não institucionalizados. Actas do 7º Congresso Nacionald e Psicologia da Saúde. 2008; 217-220.
Araújo F, Pais Ribeiro J, Oliveira A, Pinto C. Validação do Índice de Barthel numa amostra de idosos não institucionalizados. Rev Port Saúde Pública. 2007; 25: 59-66.
Stolov WC, Hayes RM, Kraft GH. Treatment strategies in chronic disease and disability: a contemporary approach to medical practice. Demos; 1994.
Downloads
Published
How to Cite
Issue
Section
License
Copyright statement
Authors must also submit a copyright statement (as seen below) on article submission.
To the Editor-in-chief of the SPMFR Journal:
The below signed author(s) hereby state that the article
________________________________________ (ref. MFR_________) is
an original unpublished work and all facts stated are a product of the author(s) investigation. This article does not violate any copyright laws or privacy statements. The author(s) also hereby confirm that there is no conflict of interest's issues in this article.
By submitting this article the author(s) agree that after publication all copyrights belong to the SPMFR Journal.
Signed by all authors
Date:
Names (capital letters):
Signatures:
The SPMFR Journal’s contents are follow a Creative Commons licence. After publication the authors can hand out the articles as long as the SPMFR Journal is credited.
