Simulated Case Analysis Instructions
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Simulated Case Analysis Instructions
Towards the end of this course, you will select a client or patient for a simulated case analysis. The rubric and instructions for this assessment is located within the Getting Started Section of the course.
You are to perform an actual or mock assessment of a patient. Please gain consent as dictated by your respective state/region/country guidelines.
You will record a full video or compiled video snippets of the actual assessment.Consider and respect patient and client anonymity and privacy. Also, please follow your respective institutional, state, regional, country guidelines. There should only be one playable video, edited or unedited.
The assessment shall cover the following areas:
PATIENT DESCRIPTION AND DEMOGRAPHICS (5%) (Gender, Age, Race, Height, Weight and/or BMI, Orientation, Marital Status: If single, do you live alone? If married, how many years?, Children, Grandchildren, Occupation including work duties, Self-Presentation/Appearance)
CASE CHIEF COMPLAINT (5%): (does not include actual diagnosis) PRESENTING SITUATION (5%): (write a few sentences about the patients’ presenting problem)
SUBJECTIVE INFORMATION (20%): (provide chief complaint, secondary complaints if any, mechanism of injury, thorough medical history, previous medical/psychiatric/therapeutic histories, history of physical activity and exercise, perspectives towards physical therapy, sleep disturbance/sleep patterns, nutrition status, perspectives on movement in general) *use scales/measures if necessary.
PSYCHOSOCIAL STATUS (10%): (economic status, work/employment status, family and current support systems, relationship status, substance abuse history, positive support systems)
OBJECTIVE INFORMATION (30%): (perform the objective tests you deem necessary and important for this case)
DIFFERENTIAL SCREENING (10%): (general systems screening, yellow and red flag screening, list competing diagnostic possibilities)
ACTUAL DIAGNOSIS (5%): As provided by referring physician, if any.
PHYSICAL THERAPY DIAGNOSIS (10%): (write the physical therapy diagnosis you have for the patient given the course’s model)
You will then submit the above video to my email [email protected] with the title: PTH 8960 SIMULATED CASE ANALYSIS/(LAST NAME).
You will include your written documentation of the evaluation/examination encounter using any format you deem appropriate for the specific case.
You will have until the final day of Week 13 to submit this video and document.
Rubric
Student Name
Score
PATIENT DESCRIPTION AND DEMOGRAPHICS
(5%) (Gender, Age, Race, Height, Weight
and/or BMI, Orientation, Marital Status: If
single, do you live alone? If married, how
many years?, Children, Grandchildren,
Occupation including work duties, Self-
Presentation/Appearance)
Provided complete, accurate data and asked relevant questions during history-taking 5%
Provided relevant, accurate, but incomplete data 3%
Provides severely incomplete, inaccurate, irrelevant, or no data 0%
CASE CHIEF COMPLAINT (5%): (does not
include actual diagnosis)
PRESENTING SITUATION (5%): (write a few
sentences about the patient’s presenting
problem)
CHIEF COMPLAINT Provides a chief complaint without a leading question
5% Did not provide a chief complaint
0%
PRESENTING SITUATION Provides a complete, relevant, accurate presenting situation derived from the patient
5% Provides incomplete or inaccurate presenting situation or did not ask relevant questions from
patient 3%
Provides no data 0%
SUBJECTIVE INFORMATION (20%): (provide
chief complaint, secondary complaints if any,
mechanism of injury, thorough medical
history, previous
medical/psychiatric/therapeutic histories,
history of physical activity and exercise,
Provides complete, relevant, accurate subjective information consistent with the history 20%
Provides relevant, accurate, but incomplete subjective data consistent with the history 15%
Provides relevant, accurate, but incomplete subjective data, but is inconsistent with the history 10%
Information is either irrelevant, inaccurate, and/or is inconsistent with history
perspectives towards physical therapy, sleep
disturbance/sleep patterns, nutrition status,
perspectives on movement in general) *use
scales/measures if necessary)
0%
PSYCHOSOCIAL STATUS (10%): (economic
status, work/employment status, family and
current support systems, relationship status,
substance abuse history, positive support
systems)
Provides complete, accurate psychological status with information relevant to the patient and their case
10% Psychological status is either incomplete, is inaccurate or is irrelevant to the case
5% Provides no psychosocial information
0%
OBJECTIVE INFORMATION (30%): (perform the
objective tests you deem necessary and
important for this case)
Objective tests are complete and relevant, are based on subjective information gathered, and are patient-specific.
30% Objective information is lacking in relevant areas but is consistent with the subjective
information gathered, and is patient-specific. Slightly incomplete. 25%
Objective information is somewhat complete but is inconsistent with the subjective information gathered, and not completely patient-specific or irrelevant tests were performed.
20% Several crucial objective tests were not performed or were not consistent with subjective
information. Contains a significant amount of irrelevant tests. 10%
Objective tests are generic, not patient-centered, and focused on diagnosis as opposed to patient-identified movement-related issues. Severely lacks crucial assessments.
0 %
DIFFERENTIAL SCREENING (10%): (general
systems screening, yellow and red flag
screening, list competing diagnostic
possibilities)
Provided a list of competing diagnostic possibilities and how they were ruled out and screened for general health issues as well as yellow and red flags.
10% Screened for general health issues, as well as yellow and red flags. Did not list nor rule out
competing diagnostic possibilities. 5%
Either did not provide a list of diagnostic possibilities, did not provide yellow and red flags, or did not perform a general systems screen.
0%
ACTUAL DIAGNOSIS (5%): As provided by the
referring physician, if any.
Provided a medical diagnosis, or mentioned that one was not provided in the history or written document
5% Incomplete medical diagnosis or did not provide a medical diagnosis but did not mention that
it was not provided nor available in patient history or within documentation 0%
PHYSICAL THERAPY DIAGNOSIS (10%): (write
the physical therapy diagnosis you have for
the patient given the course’s model)
Provided a physical therapy diagnosis in the correct format (see PowerPoint Week 12) consistent with accepted ICF guidelines.
10% Provided a physical therapy diagnosis however it is either incomplete or incorrectly formatted
5% Did not provide a physical therapy diagnosis or utilized a medical diagnosis as a PT diagnosis
0%
Total
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