Riphah College of Rehabilitation

& Allied Health Sciences

Doctor of Physical Therapy

Supervised Clinical Practice-IV
Clinical Log Book

Faculty of Rehabilitation & Allied Health

Sciences
Riphah International University
Islamabad
 STUDENT’S PROFILE

Student’s name: ______________ _

SAP ID: ____________________________ Batch: ____________________________________

Semester: ___________________ ________ Session: __________________________________

Name of hospital

Clinical Instructor: 1. ________ 2. _______________________________

3. ____________________________________ 4. _____________________________________

PRINCIPLES OF GOOD PRACTICE

 All students must be well dressed and wear overalls.

 Display your cards while visiting the clinical sites.
 Care of patients must be your first concern.
 Deal the patient politely and friendly.
 Respect patient’s dignity.
 Protect patient’s privacy.
 Respect patient’s views and problems.
 Make your attitude sympathetic to the patients.
 Use the language, understandable for the patients.
 Help your group fellows for the sake of patient’s better care.
 The ultimate goal must be to provide quality care to patients.
 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 IV
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 fourth 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
neuromuscular disorders. Students become familiar with performance of neuromuscular skills in
inpatient and outpatient setting.

Learning Instructions: Systematic review of different neurological aspects including central nervous
system, peripheral nervous system, cranial nerves integrity, 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 neuromuscular system.

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

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 16 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 16 competencies in supervised clinical practice
IV 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 patient
assessments. There are seven criterion out of twenty in SCP I which requires certain score over the
visual analogue scale (VAS) as given below:

S. No. Expected
Criterion Target
Weightage
Practices in a safe manner that
1. Safety minimizes risk to patient, self, 100%
and others.
2. Documentation Produces documentation to 75%
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 support the delivery of physical
therapy 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 treatment, outcomes, and 75%
discharge
plan.
Performs physical therapy
7. Treatment/Intervention interventions in a technically 75%
competent manner.

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 Weekly Scheme
Week Content

First Neurological History Taking/ Goal Making

Second Tone assessment

Third Assessment of reflexes

Fourth Sensory Assessment

Fifth Motor Assessment

Sixth Consciousness & Orientation Assessment

Seventh Assessment of coordination using equilibrium / non equilibrium tests

Eight Balance assessment (Static, Dynamic, Anticipatory, Reactive)
Ninth Mid Term Exams

Tenth Gait Assessment / training

Eleventh Assessment of various types of Abnormal Gaits

Twelfth Cranial nerve Assessment & Management (1-6)

Thirteenth Cranial nerve assessment & Management (7-12)

Fourteenth Vestibular Assessment & Management

Fifteenth Spinal Cord Injury Assessment

Sixteenth Functional Re-education

Seventeenth Walking/ Mobility Aids Training

Eighteenth End Term Exam

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 Section I
Clinical Cases

8
Case No.: ____________ Category: Indoor/ Outdoor Date: _______________________________

Demographics:
Name: ______________________________________________ Age: ___________________________
Gender: Male/ Female Marital status: ________________________
Language: ______________________ Occupation: __________________________
Address: ____________________________________________________________________________
(In case of Indoor category)
Mode of admission: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of admission: _________________
Present Complaint:
_______________________________________________________________________________________
_______________________________________________________________________________________
History of Presenting Complaint:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
In case of Pain as present complain:
Onset: Gradual/ Sudden Frequency: Constant/ Intermittent
Nature: Aching/ Burning/ Cramping/ Crushing/ Dull/ Numbness/ Pin & needles/ Sharp/ Shooting/
Throbbing/ Other_____________
Radiating: Yes/ No; If Yes, area of radiation: __________________________________________________
Aggravating Factors: _____________________________________________________________________
Relieving Factors: _______________________________________________________________________
Pain Intensity (Numerical Pain Rating Scale): _________________________________________________
Associated Symptoms: ____________________________________________________________________

Past Medical History:

Surgical History: ________________________________________________________________________

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Medical History: ________________

Medication/ Treatment History:

_______________________________________________________________________________________
_______________________________________________________________________________________

Family History:

_______________________________________________________________________________________
_______________________________________________________________________________________
Socioeconomic History:

_______________________________________________________________________________________
_______________________________________________________________________________________
Present & Premorbid Status:

_______________________________________________________________________________________
_______________________________________________________________________________________

Growth & Development History:

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Systems Review:

Musculoskeletal system: __________________________________________________________________

Cardiovascular system: ___________________________________________________________________

Respiratory system: ______________________________________________________________________

Gastrointestinal system: ___________________________________________________________________

Integumentary system: ____________________________________________________________________

Urogenital system: _______________________________________________________________________

1
0
On Observation:

Facial expression: ________________________________________________________________________

Attitude of the limb: ______________________________________________________________________
Posture: Sitting: ______________________________ Standing: __________________________________
Gait Assessment: ________________________________________________________________________

On Inspection:

Swelling: Yes/ No

Erythema: Yes/ No

Joint deformity: Yes/ No

Muscle wasting: Yes/ No

On Palpation:

Temperature: Symmetrical/ Asymmetrical

Tenderness: Yes/ No

Edema: Yes/ No; If Yes, Pitting/ Non pitting

Inflammatory sign: Yes/ No; If Yes, Area: ____________________ Signs: __________________________

Muscle wasting: Yes/ No; If Yes, How much difference: _________________________________________

Crepitation: Yes/ No; If Yes, Associated movement: ____________________________________________

On Examination:

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

Movement AROM PROM

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

1
1
ROM Restricted: Yes/ No; If Yes, Pattern: Capsular/ Non Capsular.

Joint Effusion: Yes/ No; If Yes, Measurement: _________________________________________________

Muscle girth: ___________________________ Limb Length: ____________________________________

MMT: (Use additional page if required)

Right Muscle Left

Sensations:

Superficial:

 Touch: Aesthesia/ Hyperesthesia/ Hypoesthesia

 Temperature: Aesthesia/ Hyperesthesia/ Hypoesthesia

 Pain: Aesthesia/ Hyperesthesia/ Hypoesthesia

Deep:

 Kinesthesia: Aesthesia/ Hyperesthesia/ Hypoesthesia

 Proprioception: Aesthesia/ Hyperesthesia/ Hypoesthesia

 Deep pressure: Aesthesia/ Hyperesthesia/ Hypoesthesia

Combined:

 Stereognosis: Aesthesia/ Hyperesthesia/ Hypoesthesia

 Graphesthesia: Aesthesia/ Hyperesthesia/ Hypoesthesia

 Two Point Discrimination: Aesthesia/ Hyperesthesia/ Hypoesthesia

Dermatomes: Level: __________________________ Outcome: ___________________________________

Myotomes: Level: ____________________________Outcome: ___________________________________

1
2
Reflexes (grade over 0, 1, 2, 3, and 4):

 Bicep tendon reflex (C5-6): __________________________________________________________

 Brachioradialis tendon reflex (C5-6): __________________________________________________

 Triceps tendon reflex (C6-7): _________________________________________________________

 Patellar tendon reflex (L2-4): _________________________________________________________

 Achilles tendon reflex (S1-2): ________________________________________________________

Primitive Reflexes (If applicable)

Abdominal reflex: _______________________________________________________________________

Rooting reflex: _________________________________________________________________________

Palmer grasp reflex: _____________________________________________________________________

Muscle Tone (apply Modified Ashworth Scale):

Right Muscle Left

Coordination (grade 0 to 4):

Non equilibrium tests:

 Finger to nose: __________________________ Finger to finger: ___________________________

 Heel on shin: ___________________________ Drawing circle: ____________________________

 Rebound Phenomena: ______________________________________________________________

Equilibrium tests:

 Sitting, weight shifting in all directions: _______________________________________________

 Sitting, multidirectional functional reach: ______________________________________________

 Standing, standing feet together: _____________________________________________________

 Standing on one foot: ______________________________________________________________

1
3
  Walk, forward, backward, sideways: __________________________________________________

Investigations: (Write the findings)

Blood test: _________________________________ X-ray: ______________________________________

CT scan: ___________________________________ MRI: ________________________

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

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

4. ___________________________________________________________________

5. ___________________________________________________________________

Goal Setting:

Short Term Goal(s):______________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________

Time to achieve short term goals: __________________________________________________________

Long Term Goal(s): _____________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________

Time to achieve long term goals: ___________________________________________________________

Plan of Care:

Manual/ Exercise Therapy: _______________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
1
4
Electrotherapy: _________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Home Plan: ____________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Precaution(s): __________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Prognosis:

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

1
5
 Section II
Competencies/ Skills

1
6
 LIST OF COMPETENCIES

1. Cognitive assessment
2. Myotomal assessment
3. Assessment of reflexes
4. Assessment of coordination using non equilibrium tests
5. Assessment of coordination using equilibrium tests
6. Assessment of tone
7. Sensory/ dermatomal assessment
8. Cranial nerve assessment
9. Balance assessment by Rhomberg and Stork tests
10. Vestibular assessment by head thrust test
11. Transfers of spinal cord injury patient
12. Application of Frenkel exercises
13. Application of Wobble board training
14. Gait training
15. Facial muscle stimulation
16. Application of facial exercises

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.

1
7
 Attempts
Level
A B C
1
(Confident)
2
(Need Assistance)
3
(No Experience)
CI Signature

Date

1
8
1 Skill: Neurological patient history taking

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

1
(Confident)

2
(Need Assistance)

3
(No Experience)

CI Signature

Date

Checklist

Discussion about the form student should 1 2 3

know about the basic documentation YES/ NO YES/ NO YES/ NO

Introduction to ICF model with example

Recognize barriers that may impact the

achievement of optimal functioning within
a predicted time frame including
•Age
•Medication(s)
•Socioeconomic status
•Co-morbidities
•Cognitive status
•Nutrition
•Social Support
•Environment
Goal Setting
Short Term Goals
Long Term Goals

1
9
2 Skill: Tone assessment

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

Greet the patient

Take consent
place the patient in comfortable position
(according to muscle)
assessment of tone

Ashworth grading

differentiate between hypotonic and

hypertonia
Compare UMN and LMN lesion

2
0
3 Skill: Assessment of reflexes

Clinical Instructor: __________________________________________________________________

Attempts
Level
A B C

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

CI Signature

Date

Components Yes/No Yes/No Yes/No

Greeting.
Take consent from the patient.
Place the patient in a comfortable sitting
position
Support the forearm on the examiners forearm
or on the patient’s lap.
Place your thumb on the bicep tendon (located
in the front of the bend of the elbow; midline to
the anticubital fossa).
Tap on your thumb to stimulate a response with
the help of reflex hammer.
Grade accordingly.

Biceps Reflex (C5 – C6):

2
1
Triceps Reflex (C7-C8):
Components Yes/No Yes/No Yes/No
Greeting.
Take consent from the patient.
Place the patient in a comfortable sitting
position
Have the individual bend their elbow while
pointing their arm downward at 90 degrees.
Support the upper arm so that the arm hangs
loosely and “goes dead”.
Tap with reflex hammer on the triceps tendon
located just above the elbow bend (funny
bone).

Grade accordingly.

Brachioradialis Reflex (C5-C6):

Components Yes/No Yes/No Yes/No
Greeting.
Take consent from the patient.
Place the patient in a comfortable sitting
position

Hold the person’s thumb so that the forearm

relaxes.

Strike the forearm about 2-3 cm above the

radial styloid process (located along the thumb
side of the wrist, about 2-3 cm above the round
bone at the bend of the wrist).

Normally, the forearm will flex and supinate.

Grade accordingly.

2
2
Quadriceps Reflex (Knee jerk) L2 – L4
Components Yes/No Yes/No Yes/No
Introduce yourself and take consent
from patient
Patient should be in a comfortable sitting
position in accordance with the test being
applied.
Examiner standing In front of the patient.
Allow the lower legs to dangle freely.
Place one hand on the quadriceps. Strike just
below the knee cap.
The lower leg normally will extend, and the
quadriceps will contract.
If the patient is supine: Stand on one side of the
bed.
Place the examiners forearm under the thigh
closest to the examiner, lifting the leg up
Reach under the thigh and place the hand on the
thigh of the opposite leg, just above the knee
cap.
Tap the knee closest to the examiner, (the one
that has been lifted up with the examiners
forearm)
Grade accordingly

Achilles Reflex (ankle jerks) L5 – S2:

Components Yes/No Yes/No Yes/No
Greeting
Take consent from the patient
Ask the patient to supine lying in a comfortable
position.

Stroke the underside of the foot from the sole

towards heel.

Positive test is when toes fan out and big toe will
move upward.

Grade accordingly

2
3
4 Skill: Sensory Assessment
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

Greeting

Take consent
Place the patient in comfortable position (according to
muscle)
Assess Superficial sensation (Pain, Temperature, Touch
& pressure)
Assess Deep sensation (Kinesthesia awareness,
Proprioception awareness &Vibration, perception)
Assess combine cortical sensation (Tactile localization,
two-point discrimination, Double simultaneous
stimulation, texture identification Graphesthesia,
Stereognosis & Barognosis)
Document accordingly

2
4
5 Skill: Motor Control Assessment

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

Greeting

Take consent
Place the patient in comfortable position
(according to muscle)
Assess muscle strength

Scales to grade MMT according to MRC

Different methods of assessing muscle

strength (Resisted isometric test, Break
test, Make test, Functional assessment,
Myometer &Dynamometer) motor
recovery stages

2
5
6 Skill: Consciousness & Orientation

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

To explain MINI mental (When to

use, component description,
Interpretation)
To explain MOCA (When to use,
component description,
Interpretation)
Defining consciousness and levels
(Lethargic, obtunded, stuporous and
comatose)
To explain Glasgow coma scale
(When to use, component
description, Interpretation)

2
6
7 Skill: Coordination assessment

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/ YES/ NO
NO
1.Greating

2.Take consent

3.place the patient in a comfortable position

4.Assess coordination test

Equilibrium test
• Sitting in a normal
comfortable position
• Sitting, weight shifting
in all directions
• Sitting, multidirectional
functional reach
• Sitting, picking an
object up off floor
2
7
 • Standing in a normal
comfortable posture
• Standing, feet together
(narrow base of support)
• Standing on one foot
• Standing, with one foot
directly in front of the other (tandem
position)
• Standing: eyes open
(eo) to eyes closed (ec) (romberg test)

Non equilibrium tests

• Finger to nose
• Finger to therapist
finger
• Finger to finger
• Alternate nose to
finger
• Mass grasp
• Finger opposition
• Rebound test
• Tapping hand
• Heel on shin
• Drawing circle
• Alternating
supination /pronation

6. treatments(Frenkel's exercise )

2
8
8 Skill: Balance assessment

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

Greeting
Take consent
Place the patient in comfortable
position
Assess is balance
Assessment of Static balance
Assessment of Dynamic balance
Assessment of Anticipatory balance
Assessment of Reactive balance

2
9
9 Skill: Gait training

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

Assessment of normal gait

Phases of gait cycle (Stance, Swing
phase)
Cadence, Step length, Stride length,
Gait Speed
Muscle Work during gait

3
0
10 Skill: Abnormal Gait training

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

Assess various types of abnormal

gait patterns
Assessment of Hemiplegic Gait
Assessment of Parkinson’s Gait

Assessment of Waddling Gait

Assessment of Trendelenburg Gait

Assessment of Spastic Diplegic

Gait

3
1
11 Skill: Cranial nerve assessment & Management

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

Greeting
Take consent
place the patient in a comfortable
position
Assess 1-6 cranial nerves

3
2
12 Skill: Cranial nerve assessment & Management

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

Greeting
Take consent
place the patient in a comfortable
position
Assess 7-12 crainal nerves

3
3
13 Skill: Vestibular assessment

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

Greeting
Take consent
place the patient in a comfortable
position
Perform Dix-Hallpike maneuver

Perform Dizziness handicap

inventory
Perform Vestibular ocular reflex

3
4
 Perform Head-thrust maneuver

14 Skill: Spinal cord injury assessment (Asia scale)

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

Greeting
Take consent
place the patient in comfortable
position
Practice Asia scale
ASIA Impairment Level assessment
Sensory, motor and neurological level
assessment.
Complete / incomplete injury

3
5
15 Skill: Functional re-education

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

Greeting
Take consent
Place the patient in comfortable
position
Bed Positioning

Components of Supine to side lying,

Components of side lying to sitting,

3
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 Sit to stand Components

16 Skill: Walking Aids

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

Identification of different parts of the

wheel chair
Transfers Bed to wheel chair, wheel
chair to bed of paraplegic patients
Use of various Crutches as mobility
aids
Gait Patterns using various mobility
aids

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Section III
Activity

3
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1 Activity: _________________________________________________________________________________

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

2 Activity: _________________________________________________________________________________

Outcome: ____________________________________________________________________________________
Problem Statement: ___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Answer: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Clinical Instructor Name: ______________________________________________________________________

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Date: ________________________ Clinical Instructor Signature: _____________________________________

3 Activity: _________________________________________________________________________________

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

4 Activity: _________________________________________________________________________________

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

4
0
5 Activity: _________________________________________________________________________________

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

6 Activity: _________________________________________________________________________________

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

4
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7 Activity: _________________________________________________________________________________

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

8 Activity: _________________________________________________________________________________

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

4
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9 Activity: _________________________________________________________________________________

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

10 Activity: ______________________________________________________________________________

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

4
3
11 Activity: ______________________________________________________________________________

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

12 Activity: ______________________________________________________________________________

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

4
4
13 Activity: ______________________________________________________________________________

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

14 Activity: ______________________________________________________________________________

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

4
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15 Activity: ______________________________________________________________________________

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

16 Activity: ______________________________________________________________________________

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

4
6
 Section IV
Clinical Performance Instrument (CPI)

4
7
 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 treatment accordingly.
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: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4
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 2. Documentation

Produces documentation to 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: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4
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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 status in:
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: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

5
0
 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

Midterm Comments: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

5
1
 _____________________________________________________________________________________
5. Evaluation/ Diagnosis/ Prognosis

Evaluates clinical findings to determine physical therapy diagnoses and outcomes of 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 prognosis within 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.

Midterm Final

Midterm Comments: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5
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 _____________________________________________________________________________________
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 outcomes that 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
clinical experience.

Midterm Final

Midterm Comments: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5
3
 _____________________________________________________________________________________
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.

Midterm Final

Midterm Comments: __________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Final Term Comments: ________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5
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_____________________________________________________________________________________
_____________________________________________________________________________________
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: ___________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_______________________________________________________________________________

Student Name & Signature: ____________________________________________________________

Clinical Instructor Name & Signature: __________________________________________________

Final Term: _________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_______________________________________________________________________________

Student Name & Signature: ____________________________________________________________

5
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Clinical Instructor Name & Signature: __________________________________________________
Areas of Needing Improvement

Midterm: ___________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

______________________________________________________________________________

Student Name & Signature: ____________________________________________________________

Clinical Instructor Name & Signature: __________________________________________________

Final Term: _________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

______________________________________________________________________________

Student Name & Signature: ____________________________________________________________

Clinical Instructor Name & Signature: __________________________________________________

5
6
 EVALUATION SIGNATURES

Midterm Evaluation:

Student Name & Signature Date

Clinical Instructor Name & Signature Date

HOD Clinical Name & Signature Date

HOD Boys/ Girls Name & Signature

5
7
Final Term Evaluation:

Student Name & Signature Date

CI Name & Signature Date

HOD Clinical Name & Signature Date

HOD Boys/ Girls Name & Signature Date

5
8
5
9