2367A_MSKPOCPatientScale
2
MUSCULOSKELETAL PROGRAM OF CARE | 2014 1 P A T I E N T - S P E C I F I C F U C T I O A L S C A L E ( P S F S ) Patient-Specific Functional Scale (PSFS) Patient-Speci fic Functional Scale 1 (PSFS) MUSCULO SKELET AL PROGRAM OF CARE (MSK POC) Read at Initial Assessment I’m going to ask you to identify 3 to 5 important activities that you are unable to do or are having difficulties with as a result of your injury. Today, are there any activities that you are unable to do or have difficulties with because of your injury? (Clinician, show scale). Please include at least two work-rela ted tasks. Read at follow-up visits When I assessed you on (state previ ous assessment date), you told me that you had difficulty with (read all activities from list, one at a time). Today, do you still have difficulty with: (read and have patient score each item in the list)? 0 1 2 3 4 5 6 7 8 9 10 Unable to perform activity. Able to perform activity at same level as before injury. Patient-specific activity scoring scheme (Point to number): Patient-Specific Functional Scale (PSFS) Functional activity: Date: Score: 1. 2. 3. 4. 5. 2367A (06/14) © 2014 Workplace Safety and Insurance Board 1 ©1995 P . Stratford, adapted with permission Clinicians to read and fill in Functional Goal and Outcome Sheet. Note: Complete at the end of the history and prior to the physical examination.
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Transcript of 2367A_MSKPOCPatientScale
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MUSCULOSKELETAL PROGRAM OF CARE | 2014 1
PAT
IENT-SPECIFIC FU
NCT
ION
AL SCA
LE (PSFS)
Patient-Specific Functional Scale (PSFS)
Patient-Specific Functional Scale1 (PSFS)
MUSCULOSKELETAL PROGRAM OF CARE (MSK POC)
Read at Initial AssessmentIm going to ask you to identify 3 to 5 important activities that you are unable to do or are having
difficulties with as a result of your
injury. Today, are there any activities that you are unable to do or have difficulties with because
of your injury? (Clinician, show scale). Please include at least two work-related tasks.
Read at follow-up visitsWhen I assessed you on (state previous
assessment date), you told me that you had difficulty with (read all activities from list,
one at a time).
Today, do you still have difficulty with: (read and have patient score each item in the list)?
0 1 2 3 4 5 6 7 8 9 10Unable to perform
activity.Able to perform
activity at same level as before injury.
Patient-specific activity scoring scheme (Point to number):
Patient-Specific Functional Scale (PSFS)
Functional activity: Date: Score:
1.
2.
3.
4.
5.
2367A (06/14) 2014 Workplace Safety and Insurance Board 1 1995 P. Stratford, adapted with permission
Clinicians to read and fill in Functional Goal and Outcome Sheet. Note: Complete at the end of the history and prior to the physical examination.
