Riphah College of Rehabilitation

& Allied Health Sciences

Doctor of Physical Therapy

Supervised Clinical Practice-V
Clinical Log Book

Faculty of Rehabilitation & Allied Health

Sciences
Riphah International University
Islamabad
 STUDENT’S PROFILE

Student’sname: ______________ _

SAP ID: ____________________________ Batch: ____________________________________

Semester: ___________________ ________ Session: __________________________________

Nameofhospital

Clinical Instructor: 1. ________ 2. _______________________________

3. ____________________________________ 4. _____________________________________

PRINCIPLES OF GOOD PRACTICE

 All students must be well dressed and wearoveralls.

 Display your cards while visiting the clinical sites.
 Care of patients must be your firstconcern.
 Deal the patient politely andfriendly.
 Respect patient’sdignity.
 Protect patient’sprivacy.
 Respect patient’s views andproblems.
 Make your attitude sympathetic to thepatients.
 Use the language, understandable for thepatients.
 Help your group fellows for the sake of patient’s bettercare.
 The ultimate goal must be to provide quality care topatients.
 CLINICAL EXPECTATION
During this clinical experience, students will spend one day per week in the clinical setting for a total of
16 days (144 contact hours) during the semester. Each student will be supervised by a clinical instructor
that has been assigned by the principal RCRAHS. The student will demonstrate the appropriate levels of
competency for the knowledge, skills, and abilities outlined on the Supervised Clinical Practice V
curriculum. Students who do not achieve the minimum expectation in a category must submit a plan for
improvement addressing each of these areas. Failure to submit a plan for improvement, as deemed
satisfactory by course coordinator, will result in a failing grade in the course.

Course Description: This course is the fifth in a sequence of six clinical education courses. This course
will provide the student with professional exposure to the clinical practice of physical therapy and is an
integrated clinical experience designed to allow for the application of didactic information acquired
through the curriculum thus far. During this supervised clinical practice, students are responsible for
successful execution of examination, evaluation, and interventions relating to cardiopulmonary
disorders. Students become familiar with performance of cardiopulmonary skills in inpatient and
outpatient setting.

Learning Instructions:Systematic review of different cardiopulmonary aspects including performing

cardiopulmonary tests and measures, clinical observation, history taking, critical discussion, skill
performance, lecture etc.

Course Goals: Upon successful completion of this course students will be:

1. Exhibit independent clinical review of cardiopulmonary system.

2. Capable to generate a clinical hypothesis that supports the clinical findings in

cardiopulmonaryreview.

3. Demonstrate critical inquiry based on logical correlation of patient data.

4. Exhibit good ethical practice.

5. Able to set the goal setting and plan the physical therapy treatment to achieve the set goals.

Core Performance Standards: Includes and assumes that students enter the program with a minimum
level of ability in specific areas, termed technical standards, and will continue to develop those and
additional skills and attitudes, called the professional behaviors.

Technical Standards: For successful completion of degree requirements, students must be able to meet
following minimum technical standards.
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1. Observation Skills:Observation requires the functional use of vision, hearing, somatic
sensations, and the use of common sense. Candidates must have visual perception which
includes depth and acuity. The student must be able to observe a patient accurately, observe
digital and waveform readings and other graphic images to determine a patient’s condition.
Candidates must be able to observe patients and be able to obtain an appropriate medical history
directly from the patient or guardian. Examples in which these observational skills are required
include: palpation of peripheral pulses, bony prominences and ligamentous structures; visual and
tactile evaluation for areas of inflammation and visual and tactile assessment of the presence and
degree of edema. A student must be able to observe a patient accurately at a distance and close
at hand, noting nonverbal as well as verbal signals.

2. Communication Skills: Includes speech, language, reading, writing and computer literacy.
Students must be able to communicate effectively, sensitively, and convey a sense of
compassion and empathy with patients to elicit information regarding mood and activities, as
well as perceive non-verbal communications. Students must be able to communicate quickly,
effectively and efficiently in oral and written English/ Urdu with all members of the health care
team. Students must be able to complete forms according to directions in a complete and timely
fashion. Students must be able to use computer technology competently and in accordance with
University hospital standards.

3. Motor/Psychomotor Skills: Students must possess sufficient motor function to elicit

information from the patient examination, by palpation, auscultation, tapping and other
evaluation maneuvers. Students must be able to execute movements required to provide general
and therapeutic care.

4. Intellectual – Conceptual Integrative and Quantitative Analysis Abilities:To effectively

solve problems, students must be able to measure, calculate, reason, analyze, integrate and
synthesize information in a timely fashion. For example, the student must be able to synthesize
knowledge and integrate the relevant aspects of a patient’s history, physical examination, and
laboratory data, provide a reasoned explanation for likely therapy, recalling and retaining
information in an efficient and timely manner. The ability to incorporate new information from
peers, teachers, and the medical literature in formulating treatment and plans is essential.

5. Behavioral/Social Attributes and Professionalism:A student must possess the psychological

ability required for the full utilization of their intellectual abilities, for the exercise of good

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 judgment, for the prompt completion of all responsibilities inherent to diagnosis and care of
patients, and for the development of mature, sensitive, and effective relationships with patients.
Students must be able to tolerate physically and mentally taxing workloads and function
effectively under stress.

Professional Behaviors:The program expects DPT students to develop and demonstrate 10

professional behaviors important to the practice of physical therapy.

1. Critical Thinking: The ability to question logically; identify, generate and evaluate elements of
logical argument; recognize and differentiate facts, appropriate or faulty inferences, and
assumptions; and distinguish relevant from irrelevant information. The ability to appropriately
utilize, analyze, and critically evaluate scientific evidence to develop a logical argument, and to
identify and determine the impact of bias on the decision making process.

2. Communication: The ability to communicate effectively (i.e. verbal, non-verbal, written, etc.)

3. Problem Solving:The ability to recognize and define problems, analyze data, develop and
implement solutions, and evaluate outcomes.

4. Interpersonal Skills:The ability to interact effectively with patients, families, colleagues, other
health care professionals, and the community in a culturally aware manner.

5. Responsibility: The ability to be accountable for the outcomes of personal and professional
actions and to follow through on commitments that encompass the profession within the scope
of work, community and social responsibilities.

6. Professionalism: The ability to exhibit appropriate professional conduct and to represent the
profession effectively while promoting the growth/development of the Physical Therapy
profession.

7. Use of Constructive Feedback: The ability to seek out and identify quality sources of feedback,
reflect on and integrate the feedback, and provide meaningful feedback to others.

8. Effective Use of Time and Resources:The ability to manage time and resources effectively to
obtain the maximum possible benefit.

9. Stress Management: The ability to identify sources of stress and to develop and implement
effective coping behaviors; this applies for interactions for: self, patient/clients and their
families, members of the health care team and in work/life scenarios.

10. Commitment to Learning:The ability to self-direct learning to include the identification of

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 needs and sources of learning; and to continually seek and apply new knowledge, behaviors, and
skills.
References: Adapted from: Warren May, PT, MPH, Laurie Kontney PT, DPT, MS and Z. Annette Iglarsh, PT, PhD, MBA: Professional
Behaviors for the 21st Century, 2009-2010

ORGANIZATION OF CLINICAL LOG BOOK

Clinical log book constitutes of four sections including cases, skill/competency, activity and clinical
performance instrument.

1. Cases: Student will document all the relevant information taken from direct/ indirect interview,
patient previous and current record, laboratory, radiological and other findings in an objective
pattern in this section. The clinical instructor will provide the feedback against each recording of
data to improve the quality, extraction and documentation abilities of the student. The student
must record 14 cases in a semester from indoor and outdoor settings.

2. Skills:Performance of pre-defined competencies over the live patient/ simulated patients and the
clinical instructor will mark the competency as either Level 1 (confident), Level 2 (need
assistance) and Level 3 (no experience). There are 15 competencies in supervised clinical practice
V and every student will be provided three attempts for each competency to get level 1 score.

3. Activity: A clinical problem will be shared to a group or individual for critical thinking and
develop a discussion among the peers in which the clinical instructor will focus on cognitive skills
including the interpretation of data, goal settings, plan of care designing etc.The student must
complete 16 activities in a semester.

4. Clinical Performance Instrument (CPI): To evaluates knowledge, skills, and attitudes and
incorporates multiple sources of information to make decisions about readiness to practice for a
student. Sources of information may include clinical performance evaluations of students,
classroom performance evaluations, students’ self‐assessments, peer assessments, and
patientassessments. There are seven criterion out of twenty in SCP V which requires certain score
over the visual analogue scale (VAS) as given below:

S. No. Criterion Target Expected Weightage

Practices in a safe manner that
1. Safety minimizes risk to patient, self, and 100%
others.
Produces documentation to support
2. Documentation 75%
the delivery of physical therapy
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 services.
Adapts delivery of physical
therapy care to reflect respect for
3. Individual/Cultural Differences 75%
and sensitivity to individual
differences.
Performs a physical therapy
4. Examination 75%
patient examination.
Evaluates clinical findings to
Evaluation/Diagnosis/
5. determine physical therapy 75%
Prognosis
diagnoses and outcomes of care.
Designs a physical therapy plan of
care that integrates goals,
6. Plan of Care 75%
treatment, outcomes, and discharge
plan.
Performs physical therapy
7. Treatment/Intervention interventions in a technically 75%
competent manner.

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 Weekly Scheme

Content Checklist
Ankle Brachial Index Patient Consent/Greetings
Therapist position
Patient position and Instructions (if any)
Performance: BP Cuff placement and
Brachial/Ankle systolic Pressure measurement
Chest Examination (Shape of chest, Patient Consent/Greetings
Symmetry of chest, Chest wall Therapist position
pain/tenderness, Intercostal spaces, Patient position and Instructions (if any)
Respiratory excursion, tactile fermatas. Hand Placement
Percussion Note Performance
Pulmonary Auscultation Patient Consent/Greetings
Therapist position
Patient position and Instructions (Deep inhalation
and exhalation)
Stethoscope Placement
Performance

CVS EXAMINATION: Auscultation of Patient Consent/Greetings

Heart Sounds Therapist position
Patient position
Stethoscope Placement
Performance

Apex beat Patient Consent/Greetings

Clinical Sign and symptoms from Therapist position
cardiovascular system: Patient position
Dyspnea scale, Orthopnea, Paroxysmal Hand Placement
nocturnal dyspnea, Syncope, Palpitations, Performance

ECG (6 and 12 seconds) Heart rate and Rythm

P wave (Normal shape? Present? Followed by
QRS?)
PR interval (Normal? Short? Long? Irregular?)
QRS interval (Normal? Short? Long? Irregular?)
ST segment (Generally a normal shape?)
T wave (Normally shaped? Tall? Short? Wide?)
U wave (Present?)

Target HR calculation through karvonen Calculation of:

formula Resting HR
Maximum HR
HR reserve
Range of minimum- maximum THR

Aerobic endurance test (10 meter walk Mark 10 m distance

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test) Pre-Vitals
Walk for 10 m distance
Post-Vitals
RPE (Borg)
Mid Term Exams
Chest x ray: Observation and Chest X- Image quality (RIPE):
rays report interpretation. Rotation
Inspiration
Projection
Exposure
ABCDE approach 

POSTURAL DRAINAGE Patient Consent/Greetings

Manual/mechanical techniques, chest Therapist position
Percussion, vibration, shaking Patient position for all segments
Hand Placement and position(for percussion
vibration and shaking)
Performance

Movement strategies, Relaxation Patient Consent/Greetings

techniques and Positioning: Therapist position
Patient position and Instructions
Performance

Breathing strategies: Patient Consent/Greetings

Therapist position
Deep breathing, Diaphragmatic
Patient position and Instructions
breathing, Paced breathing, Segmental
Performance
breathing and Glossopharyngeal
breathing, Pursed lip breathing
Active cycle of breathing or forced
expiratory techniques

Airway clearance techniques: Patient Consent/Greetings

Assisted cough/ huff techniques, Tracheal Therapist position
tickle. Patient position and Instructions
Hand Placement (if required)
Performance
Orthostatic hypotension Functionality Patient Consent/Greetings
measurement before mobility Therapist position
Patient position and Instructions
Take Vitals (BP, HR) in:
Lying position
Sitting
Standing

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Aerobic conditioning Program Warm up
Aerobic conditioning (Walk, stair
climbing ) according to FITT
Cool down
End Term Exam

Section I
9
Clinical Cases

1
0
Case No.: ____________ Category: Indoor/ Outdoor Date: _______________________________

Demographics:
Name: ______________________________________________ Age: ___________________________
Gender: Male/ Female Maritalstatus: ________________________
Language: ______________________ Occupation: __________________________
Address: ____________________________________________________________________________
(In case of Indoor category)
Mode ofadmission: _ __ __ __ __ __ __ __ __ _ Dateofadmission: _________________
Present Complaint:
_______________________________________________________________________________________
_______________________________________________________________________________________
History of Presenting Complaint:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Past Medical History:

SurgicalHistory: ________________________________________________________________________
MedicalHistory: ________________

Medication/ Treatment History:

_______________________________________________________________________________________
_______________________________________________________________________________________

Family History:

_______________________________________________________________________________________
_______________________________________________________________________________________
Socioeconomic History:

1
1
_______________________________________________________________________________________
_______________________________________________________________________________________
Present & Premorbid Status:

_______________________________________________________________________________________
_______________________________________________________________________________________

Growth & Development History:

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

General Health Status:

Level of awareness: _____________________________________ Body type: _______________________

Lymph nodes: _________________________________ Thyroid status: ____________________________

Height: ____________ Weight: _______________________ Body mass index: ______________________

Vitals:

Respiratory rate: _______________________ Pulse: ______________________ Temperature: __________

Oxygen Saturation (SpO2): _________________________ Blood pressure: _________________________

Systems Review:

Musculoskeletal system: __________________________________________________________________

Neurological system: _____________________________________________________________________

Gastrointestinal system: ___________________________________________________________________

Integumentary system: ____________________________________________________________________

Urogenital system: _______________________________________________________________________

On Observation:

Dyspnea: Mild/ Moderate/ Severe; Resting/ Exertional

1
2
Orthopnea: Yes/ No Palpitations: Yes/ No

Chest pain: Mild/ Moderate/ Severe; Resting/ Exertional

Cough: Productive/ Dry

Sputum Color: ___________________________ Amount of Sputum: __________________________

Hemoptysis: Yes/ No Syncope: Yes/ No

Peripheral Edema: Yes/ No Clubbing: Yes/ No

Cynosis: Central/ Peripheral Anemia: Yes/ No

Nausea: Yes/ No Vomiting: Yes/ No

Fatigue: Yes/ No

On Inspection:

Chest shape: Symmetrical/ Asymmetrical; Barrel/ Funnel/ pigeon shaped

Chest movements: Symmetrical/ Asymmetrical

Breathing pattern: Abdomino-thoracic/ Thoraco-abdominal/ Others (Specify) ________________________

Tracheal position: Central/ Right shift/ Left shift

Intercostal spaces: Normal/ Bulging (Right/ Left)/ Retracted (Right/ Left)

Cutaneous signs: Janeway lesion/ Osler’s node/ Splinter hemorrhage/ Others (Specify) _________________

Extremities: Sweaty/ Dry

On Palpation:

Chest wall tenderness/ pain: Yes/ No Extremities: Cold/ Warm/ Normal

Tactile fremitus: _________________________________________________________________________

Chest excursion:

 Anteriorly; Normal/ Decreased on Right/ Left side

 Posteriorly; Normal/ Decreased on Right/ Left side

Pulse:

 Carotid: Yes/ No; Regular/ Irregular/ Regularly irregular

1
3
  Radial: Yes/ No; Regular/ Irregular/ Regularly irregular

 Popliteal: Yes/ No; Regular/ Irregular/ Regularly irregular

 Dorsalispedis: Yes/ No; Regular/ Irregular/ Regularly irregular

Apex beat: Palpable/ Non-palpable

On Examination:

Percussion: (Normal = N; Dull = D; Hyperresonant = H)

 Right Anterior: 2 ___________ 4 ____________ 6 ____________

 Left Anterior: 2 ___________ 4 ____________ 6 ____________

 Right Posterior: 2 ___________ 4 ____________ 6 ____________

 Left Posterior: 2 ___________ 4 ____________ 6 ____________

 Right Lateral: 4 ___________ 6 ____________ 8 ____________

 Left Lateral: 4 ___________ 6 ____________ 8 ____________

Auscultation:

Breath sounds: __________________________________ Pattern: _________________________________

Air entry: ______________________________________________________________________________

Added sounds: Wheeze/ Crepitation/ Pleural rub/ Stridor; audible in ________________________________

Heart sounds: __________________________________ Murmors: ________________________________

Adventitious sounds: Pericardial friction rub/ Ejection click/ Opening snap

Range of Movement of ____________________________ (Use additional page if required)

Movemen AROM PROM

t Right End Feel Left End Feel Right End Feel Left End Feel

1
4
Muscle girth: ___________________________ Limb Length: ____________________________________

Investigations: (Write the findings)

Blood test: _________________________________X-ray: ______________________________________

CT scan: ___________________________________ MRI:________________________

ECG: ____________________________________________________________________

Echocardiography: _________________________________________________________

ETT: ____________________________________________________________________

Special Tests:

Borg scale: _______________________________________________________________

Orthopnea scale: ___________________________________________________________

6MWT: __________________________________________________________________

Ankle brachial index: _______________________________________________________

HR Max: _______________________________ Target HR: ________________________

Digital spirometer: _______________________ METs: ___________________________

Exercise protocol (Bruce): ___________________________________________________

Assessment: (List all the impairments with possible clinical reason)

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

4. ___________________________________________________________________

5. ___________________________________________________________________

Goal Setting:

Short Term Goal(s):______________________________________________________________________

______________________________________________________________________________________

1
5
______________________________________________________________________________________
______________________________________________________________________________________

Time to achieve short term goals: __________________________________________________________

Long Term Goal(s): _____________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Time to achieve long term goals: ___________________________________________________________

Plan of Care:

Manual/ Exercise Therapy: _______________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Electrotherapy: _________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Home Plan: ____________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Precaution(s): __________________________________________________________________________
1
6
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Prognosis:

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

1
7
 Section II
Competencies/ Skills

1
8
 LIST OF COMPETENCIES
1. Ankle brachial index
2. Chest Symmetry
3. Percussion note
4. Auscultation of breath sounds
5. Apex beat
6. Auscultation of heart sounds
7. ECG interpretation
8. Chest X-ray interpretation
9. HR, HR Max, Target HR calculation
10. Aerobic endurance test
11. Breathing strategies
12. Airway clearance technique
13. Maximization of ventilation
14. Movement strategies
15. Orthostatic hypotension

Competency Level: three levels to mark the students’ performance by clinical instructors against each
competency.
 Level 1:Confident – has experience with ability, requires little or no supervision.
 Level 2: Need assistance – has some experience with skill, requires moderate supervision.
 Level 3: No experience with skills, requires close supervision.
Attempts: The student has three attempts to improve his/ her performance in each competency with the
help of clinical instructor.
Attempts
Level
A B C
1
(Confident)
2
(Need Assistance)
3
1
9
(No Experience)
CI Signature
Date

2
0
1 Skill: Ankle brachial index

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)

2
(Need Assistance)

3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
Patient position and
Instructions (if any)
Performance: BP Cuff
placement and
Brachial/Ankle systolic
Pressure measurement

2
1
2 Skill: Chest Symmetry

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
Patient position and
Instructions (if any)
Hand Placement
Performance

2
2
3 Skill: Percussion note

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
Patient position and
Instructions (if any)
Hand Placement
Performance

2
3
4 Skill: Auscultation of breath sounds

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
Patient position and
Instructions (Deep
inhalation and exhalation)
Stethoscope Placement
Performance

2
4
5 Skill: Apex beat

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
Patient position
Hand Placement
Performance

2
5
6 Skill: Auscultation of heart sounds

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
Patient position
Stethoscope Placement
Performance

2
6
7 Skill: ECG interpretation

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Heart rate and Rythm

P wave (Normal shape?
Present? Followed by
QRS?)
PR interval (Normal?
Short? Long? Irregular?)
QRS interval (Normal?
Short? Long? Irregular?)
ST segment (Generally a
normal shape?)
T wave (Normally shaped?
2
7
Tall? Short? Wide?)
U wave (Present?)

8 Skill: Chest X-ray interpretation

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Image quality (RIPE):

Rotation
Inspiration
Projection
Exposure
ABCDE approach 
2
8
9 Skill: HR, HR Max, Target HR calculation

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Calculation of:
Resting HR
Maximum HR
HR reserve
Range of minimum-
2
9
maximum THR

10 Skill: Aerobic endurance test

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)
CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Mark 10 m distance
Pre-Vitals
Walk for 10 m distance
Post-Vitals
RPE (Borg)

3
0
11 Skill:Breathing strategies

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
3
1
Patient position and
Instructions
Performance

12 Skill:Airway clearance technique

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
3
2
Therapist position
Patient position and
Instructions
Hand Placement (if
required)
Performance

13 Skill: Maximization of ventilation

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

3
3
Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
Patient position and
Instructions
Hand Placement (if
required)
Performance

14 Skill: Movement strategies

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

3
4
Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
Patient position and
Instructions
Performance

15 Skill: Postural Hypotension

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)
2
(Need Assistance)
3
(No Experience)

CI Signature

Date

Checklist

3
5
Component 1 2 3
YES/ NO YES/ NO YES/ NO

Patient Consent/Greetings
Therapist position
Patient position and
Instructions
Take Vitals (BP, HR) in:
Lying position
Sitting
Standing

Section III
Activity
3
6
1 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

3
7
2 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

3 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

3
8
4 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

5 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

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6 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

7 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

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8 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

9 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

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10 Activity: ______________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

11 Activity: ______________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

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12 Activity: ______________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

13 Activity: ______________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

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14 Activity: ______________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

15 Activity: ______________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

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16 Activity: ______________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________
Date: ________________________ Clinical Instructor Signature: _____________________________________

Section IV
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 Clinical Performance Instrument (CPI)

1. Safety

Practices in a safe manner that minimizes risk to patient, self, and others.

SAMPLE BEHAVIORS
i. Observes health and safety regulations.
ii. Maintains safe working environment.
iii. Recognizes physiological and psychological changes in patient and adjusts treatmentaccordingly.
iv. Demonstrates awareness of contraindications and precautions of treatment.
v. Requests assistance when necessary.
vi. Uses acceptable techniques for safe handling of patients.

M F M F
Not Observed Novice Clinical Entry‐Level Performance Exceeds Entry‐Level
Performance

Significant Concerns: Check below if performance on this criterion places student at risk of failing this
clinical experience.
Midterm Final

Midterm Comments:__________________________________________________________________

_____________________________________________________________________________________
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 _____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments:________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. Documentation

Produces documentationto support the delivery of physical therapy services

SAMPLE BEHAVIORS
i. Selects relevant information to document the delivery of physical therapy patient care.
ii. Documents all aspects of physical therapy care, including screening, examination, evaluation,
plan of care, treatment, response to treatment, discharge planning, family conferences/ counseling,
and communication with others involved in delivery of patient care.
iii. Produces documentation that follows guidelines and format required by the practice setting.
iv. Produces documentation that is accurate, concise, timely and legible.
v. Demonstrates professionally and technically correct written communication skills.

M F M F
Not Observed Novice Clinical Entry‐Level Performance Exceeds Entry‐Level
Performance

Significant Concerns: Check below if performance on this criterion places student at risk of failing this
clinical experience.
Midterm Final

Midterm Comments:__________________________________________________________________

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_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments:________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

3. Individual/ Cultural Differences

Adapts delivery of physical therapy care to reflect respect for and sensitivity to individual differences

SAMPLE BEHAVIORS
Exhibits sensitivity to differences in race, creed, color, gender, age, national or ethnic origin,
sexual orientation and disability or health statusin:
a. Communicating with others
b. Developing plans of care
c. Implementing plans of care

M F M F
Not Observed Novice Clinical Entry‐Level Performance Exceeds Entry‐Level
Performance

Significant Concerns: Check below if performance on this criterion places student at risk of failing this
clinical experience.
Midterm Final

Midterm Comments:__________________________________________________________________

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 _____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments:________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

4. Examination

Performs a physical therapy patient examination of musculoskeletal scope.

SAMPLE BEHAVIORS
i. Selects reliable and valid physical therapy examination methods relevant to the chief complaint,
results of screening, and history of the patient.
ii. Obtains accurate information by performing the selected examination methods.
iii. Adjusts examination according to patient response.
iv. Performs examination minimizing risks to the patient, self, and others involved in the delivery of
the patient’s care.
v. Performs physical therapy examination procedures in a technically competent manner.

M F M F
Not Observed Novice Clinical Entry‐Level Performance Exceeds Entry‐Level
Performance

Significant Concerns: Check below if performance on this criterion places student at risk of failing this
clinical experience.

Midterm Final

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 Midterm Comments: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5. Evaluation/ Diagnosis/ Prognosis

Evaluates clinical findings to determine physical therapy diagnosesandoutcomesof care.

SAMPLE BEHAVIORS
i. Synthesizes examination data to complete the physical therapy evaluation.
ii. Interprets clinical findings to establish a diagnosis within the practitioner’s knowledge base.
iii. Identifies competing diagnoses which must be ruled out to establish a diagnosis.
iv. Explains the influences of pathological, pathophysiological, and pharmacological processes on the
patient’s movement system.
v. Identifies other medical, social, or psychological problems influencing physical therapy and not
identified through diagnosis of a patient’s problem.
vi. Uses clinical findings and diagnosis to establish a prognosiswithin the practitioner’s knowledge base.
vii. Evaluates changes in patient status.

M F M F
Not Observed Novice Clinical Entry‐Level Performance Exceeds Entry‐Level
Performance

Significant Concerns: Check below if performance on this criterion places student at risk of failing this
clinical experience.
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 Midterm Final

Midterm Comments: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
6. Plan of Care

Designs a physical therapy plan of care that integrates goals, treatment, outcomes, and discharge plan

SAMPLE BEHAVIORS
i. Establishes goals and desired functional outcomesthat specify expected time durations.
ii. Establishes a physical therapy plan of care in collaboration with the patient, family, caregiver, and
others involved in the delivery of health services.
iii. Establishes a plan of care consistent with the examination and evaluation.
iv. Establishes a plan of care minimizing risk to the patient
v. Establishes a plan of care designed to produce the maximum patient outcome(s) utilizing available
resources.
vi. Adjusts the plan of care in response to changes in patient status.
vii. Selects intervention g strategies to achieve the desired outcomes.
viii. Establishes a plan for patient discharge in a timely manner.

M F M F
Not Observed Novice Clinical Entry‐Level Performance Exceeds Entry‐Level
Performance

Significant Concerns: Check below if performance on this criterion places student at risk of failing this
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 clinical experience.

Midterm Final

Midterm Comments: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
7. Treatment/ Intervention

Performs physical therapy interventions in a technically competent manner.

SAMPLE BEHAVIORS
i. Performs effective, efficient and coordinated movement in providing technically competent
interventions for patients.
ii. Performs interventions consistent with the plan of care.
iii. Provides intervention in a manner minimizing risk to self, to the patient, and to others involved in
the delivery of the patient’s care.
iv. Uses intervention time efficiently and effectively.
v. Adapts intervention to meet the individual needs and responses of the patient.

M F M F
Not Observed Novice Clinical Entry‐Level Performance Exceeds Entry‐Level
Performance

Significant Concerns: Check below if performance on this criterion places student at risk of failing this
clinical experience.

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 Midterm Final

Midterm Comments: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
SUMMATIVE COMMENTS

Given this student's level of academic and clinical preparation and the objectives for this clinical
experience, identify strengths and areas needing improvement. If this is the student's final clinical
experience, comment on the student's overall performance as a physical therapist.

Areas of Strength

Midterm:___________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Student Name & Signature: ____________________________________________________________

Clinical Instructor Name & Signature: __________________________________________________

Final Term:_________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Student Name & Signature: ____________________________________________________________

Clinical Instructor Name & Signature: __________________________________________________

Areas of Needing Improvement

Midterm:___________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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_____________________________________________________________________________________

Student Name & Signature: ____________________________________________________________

Clinical Instructor Name & Signature: __________________________________________________

Final Term:_________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Student Name & Signature: ____________________________________________________________

Clinical Instructor Name & Signature: __________________________________________________

EVALUATION SIGNATURES

Midterm Evaluation:

Student Name & Signature Date

Clinical Instructor Name & Signature Date

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HOD Clinical Name & Signature Date

HOD Boys/ Girls Name & Signature

Final Term Evaluation:

Student Name & Signature Date

CI Name & Signature Date

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HOD Clinical Name & Signature Date

HOD Boys/ Girls Name & Signature Date

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