← Differential Diagnosis class notes
FROM MY PT SCHOOL NOTES · DIFFERENTIAL DIAGNOSIS · UNIT 4 · CHAPTER 14
Referral decisions and documentation
How should a PT communicate a concerning finding? Document the observation, onset, urgency, advice, recipient and safe handoff without asserting an unsupported medical diagnosis.
Key screening concepts
- Communicate the concerning pattern, findings, onset, vitals and reason for referral rather than making unsupported diagnoses.
- Document what you observed, advice given, who was contacted, and the patient’s response; preserve safe handoff.
- Know when to stop PT, arrange same-day medical assessment, or activate emergency services, based on local protocol and patient status.
PT clinical connection
This outline is an educational aid. Follow local emergency plans, scope of practice, medical standing orders and institution policy.
High-yield distinction
Close the loop: Record what you observed, urgency, recipient, instructions given, and any communication or follow-up.
Original class sources: 3 Medical Screening Physical Assessment as a Screening Tool.pdf; 1 Intro.pdf; Interviewing Do and Do nots.pdf. Personal PT-school notes with separately indicated new references; not a diagnosis, medical clearance, emergency triage protocol or substitute for appropriate evaluation and referral pathways.
