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Clinical Log Book

The clinical log book contains details of a physical therapy student's clinical placements, including patient information, assessments, diagnoses, treatment plans and outcomes for each patient seen. It includes sections for documenting demographic data, subjective and objective findings, specialized tests, goals of care, and treatment outcomes. The log book is signed by both the student and supervising physical therapist after each patient encounter.

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6K views14 pages

Clinical Log Book

The clinical log book contains details of a physical therapy student's clinical placements, including patient information, assessments, diagnoses, treatment plans and outcomes for each patient seen. It includes sections for documenting demographic data, subjective and objective findings, specialized tests, goals of care, and treatment outcomes. The log book is signed by both the student and supervising physical therapist after each patient encounter.

Uploaded by

lecturio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CLINICAL LOG BOOK

DOCTOR OF PHYSICAL
THERAPY
DPT 6TH SEMESTER
FAISAL INSTITUTE OF HEALTH SCIENCES

Clinical log book


Student’s name:
Roll no:
Program:
Session:
Institute:

Student’s address:
Student’s Contact No:

Shaham Haroon, PT
Clinical coordinator
Faisal Institute of
Health Sciences
S.No Date Patient name Age/ Deffrential diagnosis Physical Therapy &
Gender
Outcomes
Assessment form
Faisal Institute of Health Sciences
Physical therapy & Rehabilitation
Demographic Data
Name: S/D/O

Age: Gender: Male/Female

D/D:

Ref By: Date of Admission:

Marital status: Aims:

Occupation: Address:

Subjective Part

C/O:

History of present illness:


PMH:

PSH:

AF/RF:

Psy Status:

S.E.S:

Family history:

Aims:
Objective Part:
Pain:
 Onset
 Type/Frequency of Pain: Constant Intermittent Other

 Nature Aching Burning Cramping Crushing Dull Numbness

Pins & Needles Sharp Shooting Throbbing Other, describe :

 Radiating

 Aggravating factor

 Relieving factor

 Severity (VAS)

 Associated symptoms

ADL deficiencies:

Posture:
 Lying
 Sitting
 Standing

Inspection:
 Swelling Erythema Joint Deformity Muscle wasting

 ON PALPATION: Temperature Tenderness Edema Inflammatory sign


 Muscle wasting Contractures Crepitations

 ON EXAMINATION

 Range of movement
o Active
o Passive

 Joint Effusion measurement

 Muscle girth

 Limb length

 End feel:

 Capsular

 Non-capsular

MMT:

Specialized test:

Gait assessment

Neurological test

 Dermatomes

 Myotomes
 Reflexes
o Bicep Reflex
o Tricep Reflex
o Pattlor Tendon Reflex
o Bebsinkin’s Reflex
o Planter Reflex

Systematic Review

Lab Test:
 Blood test
 X-ray
 CT scan
 MRI
Clinical Assessment

Problem Clinical Reasoning


Plan of Care

Short Term Goals:

Long Term Goals:


Home plan:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Treatment out Come at the end of the session:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
Name of the Student: ______________________________________

Registration No: ______________________________________

Program DPT: ______________________________________

Signature of student: ______________________________________

Supervisor’s Signature

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