The Physiatric History and Physical Examination

The physiatric history and physical examination (H&P) serves several purposes. It serves as a written record that communicates to other rehabilitation and nonrehabilitation health care professionals. It is the data platform from which a treatment plan is developed. Finally, the H&P provides the basis for physician billing and serves as a medicolegal document. Physician documentation has become the critical component in inpatient rehabilitation reimbursement under prospective payment (e.g., interdisciplinary plan of care, admission screening), as well as proof for continued coverage by private insurers. The scope of the physiatric H&P varies enormously, depending on the setting, from the focused assessment of an isolated knee injury in an outpatient setting, to the comprehensive evaluation of a patient with traumatic brain or spinal cord injury admitted for inpatient rehabilitation. Patients cared for in rehabilitation medicine can be extremely complicated, which should be reflected in the H&P. It should also include confirmation of historical and functional items by other team members, health care professionals, and family members. It is imperative that the physiatrist stays abreast of additional information and findings as they become available and that lines of verbal or written communication be directed through the medical leadership of the team. The exact structure of the physiatric assessment is determined in part by personal preference, training background, and institutional requirements (physician billing compliance expectations, proper linkage to resident documentation, forms committees, and regulatory oversight). Assessment of some or all of these elements is required for a complete understanding of the patient’s state of health and the illness for which he or she is being seen. These elements also form the basis for a treatment plan.