Northeastern University Physical Therapy 123 Sample Avenue Boston, MA, 02115

Dr. X, Hello, this is Zach Gordon, DPT, from Northeastern University Physical Therapy. I am writing in regards to a patient, Mr. Y, who has listed you as his PCP in his patient information, and who I am referring to you for further evaluation. Mr. Y was seen today, October 12, 2013, for an initial evaluation. The relevant findings of which are as follows: Patient Info: Pt is a 60 y/o male, married with a 25 y/o son. Works as an accountant for a large corporation. Pt seen today, c/o of SOB when mildly exercising, with mild chest pain, and difficulty performing some ADLs, due to SOB. PMH/Medications: No prior major medical interventions save for surgery to repair ACL at age 18. Pt is on daily doses of Claritin for seasonal allergies. Non-smoker, no family history of cardiopulmonary diseases or DM. Screenings: Integumentary: WNL Musculoskeletal: WNL, 5/5 for all muscle groups. Cardiopulmonary Auscultation: All heart and lung sounds normal. Resting VS (sitting): HR-79, BP-120/80, RR-13, O2Sat-98%. 6-Lead ECG (10/12/13): NSR was observed, however PACs occurred at an abnormal rate, at approx. 3 PACs/min. Since Pt has no prior arrhythmias, I chose to stop treatment. I am referring Mr. Y back to you for further cardiac evaluation. Additionally, the findings listed here represent only a fraction of the full examination performed in the clinic, as I chose to include what I believed to be the most relevant findings to the matter. If you require more information or the full screenings, please contact me ASAP. I await your diagnosis of the condition in regards to Mr. Ys ability to participate in a physical therapy treatment regimen to improve his cardiac and pulmonary capacity in order to reduce SOB, chest pain, and resume normal ADLs w/o SOB. Please let me know if you have any further questions, I can be reached via email at xxxxxxx@xxxx.com or via telephone at (xxx)-xxx-xxxx. I look forward to hearing back from you. Sincerely, [Signature] Zach Gordon, DPT

Reflection: As discussed in previous entries, although written communication in the physical therapy field is not necessarily at the forefront of clinicians minds, it perhaps is one of the most essential parts to a physical therapists clinical life. Keeping this in mind, I wanted to tackle an aspect of this category that is oft-overlooked by many; Steering away from the typical notes, patient charts, surveys, evaluations and progress reports to a field of writing I had not yet familiarized myself. Throughout the course of a patient treatment regimen, inter-professional communication can easily make a significant difference in the effectiveness of the treatment, even resulting in matters of life-or-death. For example, if a patient comes in with a primary complaint of shoulder pain, proper communication with that patients physician can determine whether it is indeed a minor issue such as a frozen shoulder, or whether that pain is referred from a blockage in the heart, which could require immediate emergency medical intervention. This is only one example of countless reasons that this skill is crucial in a physical therapists regimen, something that I have had very little experience with, and something I wished to explore deeper when thinking about this assignment. When writing this document, word choice, tone, and use of medical terminology are crucial. The extent to which these details are used depends on many factors: severity of the situation, familiarity with the situation, familiarity with the intended health care professional, etc. In any case, it is imperative to clearly explain the situation, from prior medical history to tests and evaluations, to the utmost detail necessary for the recipient to clearly understand why they are receiving the message, interpret the necessary information, and make an informed and educated decision as to what to do next. It is assumed that standard medical abbreviations and terminology can be used, however, since this is a message and not a note, explanations and

necessary verbiage should be utilized to efficiently convey the situation. Tone can vary based on familiarity with the recipient, however standard professionalism should always be used in a situation of doubt. For this example, since I am using this opportunity to explore a previously uncharted path, I decided to ease into it by using a field of physical therapy I am currently familiar with. Since I am currently taking a class in management of cardiopulmonary physical therapy interventions, I thought this realm of PT would be a practical topic to write about. In this piece, set up as an email or letter to a patients physician, the physical therapist has just seen a patient for an initial evaluation in the clinic, where yellow flags were raised as far as subsequent physical therapy treatment. The PT is using this as an accompaniment to a referral to their physician to determine further interventions. Although I have done research on the proper techniques to these notes, firsthand experience is always the preferred way to perfect writing style in this format. It is anticipated that my writing skill in this piece will be raw and I will need quite a learning curve to better my performance after this initial attempt.