APPENDIX F - Case Based Discussion Template

CPA CLINICAL SPECIALTY PROGRAM
Clinical Case Submissions /
Candidate ID: / Date:

Either write a narrative including all of the following information, or use the template provided. The clinical cases presented must be different patient situations and are to include a variety of presentations. At least one (1) patient case should include discharge planning activities within the continuum of care or community integration.

CASE ONE

PERSONAL CONTEXT FACTORS
Age: / Gender: / Employment:
Socio-Economic Status:
Personal Health Practices:
Interests:
ENVIRONMENTAL CONTEXTUAL FACTORS
Living Situation:
Environment:
HEALTH CONDITION
Primary Complaint: / Physiotherapy Diagnosis: / Date of Dx
History of Condition:
Additional Medical History:
Diagnostic Tests:
Medications:
Functional Level/Abilities:
PATIENT/CLIENT GOALS

PHYSIOTHERAPEUTIC ASSESSMENT AND FINDINGS (test, factors for consideration)

PHYSIOTHERAPY ISSUES (please identify by number)

PHYSIOTHERAPEUTIC INTERVENTIONS (selection and rationale, treatment progression, outcomes/evaluation)

Issue / Therapeutic Goal / Therapeutic Target / Description of Intervention and rationale

DISCHARGE PLANNING (as applicable, include rationale)

INFORMATION REGARDING THE ROLE OF OTHER HEALTH CARE PROVIDERS (if involved)

SUPPLEMENTAL INFORMATION (as appropriate, include the role of the physiotherapist specialist candidate, or additional documents/files that would supplement this presentation)

COMPETENCIES DEMONSTRATED WITH THIS PATIENT CASE

CASE TWO

PERSONAL CONTEXT FACTORS
Age: / Gender: / Employment:
Socio-Economic Status:
Personal Health Practices:
Interests:
ENVIRONMENTAL CONTEXTUAL FACTORS
Living Situation:
Environment:
HEALTH CONDITION
Primary Complaint: / Physiotherapy Diagnosis: / Date of Dx
History of Condition:
Additional Medical History:
Diagnostic Tests:
Medications:
Functional Level/Abilities:
PATIENT/CLIENT GOALS

PHYSIOTHERAPEUTIC ASSESSMENT AND FINDINGS (test, factors for consideration)

PHYSIOTHERAPY ISSUES (please identify by number)

PHYSIOTHERAPEUTIC INTERVENTIONS (selection and rationale, treatment progression, outcomes/evaluation)

Issue / Therapeutic Goal / Therapeutic Target / Description of Intervention and rationale

DISCHARGE PLANNING (as applicable, include rationale)

INFORMATION REGARDING THE ROLE OF OTHER HEALTH CARE PROVIDERS (if involved)

SUPPLEMENTAL INFORMATION (as appropriate, include the role of the physiotherapist specialist candidate, or additional documents/files that would supplement this presentation)

COMPETENCIES DEMONSTRATED WITH THIS PATIENT CASE

CASE THREE

PERSONAL CONTEXT FACTORS
Age: / Gender: / Employment:
Socio-Economic Status:
Personal Health Practices:
Interests:
ENVIRONMENTAL CONTEXTUAL FACTORS
Living Situation:
Environment:
HEALTH CONDITION
Primary Complaint: / Physiotherapy Diagnosis: / Date of Dx
History of Condition:
Additional Medical History:
Diagnostic Tests:
Medications:
Functional Level/Abilities:
PATIENT/CLIENT GOALS