MANDAUE REHABILITATION CENTER

Community Based Rehabilitation

Center
Section of Physical Therapy
City Health Department – Mandaue
City, Cebu
CASE CONFERENCE GROUP EVALUATION FORM

__________________
case

PRESENTORS: ___________________________________ ___________________________________

___________________________________ ___________________________________
___________________________________ ___________________________________

PANELIST : ___________________________________

I. POWERPOINT / GROUP GRADE (300 pts total)

a. MEDICAL BACKGROUND (100 pts) SCORE
i. Definition 4 pts _____
ii. Epidemiology 4 pts _____
iii. Etiology 4 pts _____
iv. Pathophysiology 4 pts _____
v. Clinical Manifestations 10 pts _____
vi. Prognosis 8 pts _____
vii. Differential Diagnosis 10 pts _____
viii. Complications 10 pts _____
ix. Medical/Surgical Management 8 pts _____
x. Pharmacological Management 8 pts _____
xi. PT Assessment 15 pts _____
xii. PT Management 15 pts _____

TOTAL MEDICAL BACKGROUND GRADE 100 pts _____

b. INITIAL or RE-EVALUATION (100 pts)

i. Subjective (20 pts) SCORE
1. Chief Complaint 2 pts _____
2. Pt’s Goals 2 pts _____
3. Attitude of the pt. 2 pts _____
4. History of Present Illness 3 pts _____
5. Family Medical Hx 2 pts _____
6. Personal/Social Hx 3 pts _____
7. Environmental Hx 2 pts _____
8. Ancillary Procedures 2 pts _____
9. Medications 2 pts _____

TOTAL SUBJECTIVE SCORE 20 pts _____

ii. Objective (25 pts) SCORE

1. Ocular Inspection/Palpation 10 pts _____ *** ITEMS THAT SHOULD
2. Vital Signs 10 pts _____
3. Cognitive Assessment 10 pts _____
HAVE BEEN ASSESSED BUT
4. Sensory Assessment 10 pts _____ WERE NOT INCLUDED IN THE
5. _________________________ 10 pts _____ POWERPOINT PRESENTATION
6. _________________________ 10 pts _____ WILL BE GIVEN A SCORE OF 5
7. _________________________ 10 pts _____
8. _________________________ 10 pts _____ PTS
9. _________________________ 10 pts _____
10. _________________________ 10 pts _____
11. _________________________ 10 pts _____
12. _________________________ 10 pts _____
13. _________________________ 10 pts _____
14. _________________________ 10 pts _____
15. _________________________ 10 pts _____
16. _________________________ 10 pts _____
17. _________________________ 10 pts _____
18. _________________________ 10 pts _____
19. _________________________ 10 pts _____
 20. _________________________ 10 pts _____

TOTAL OBJECTIVE POINTS _____

TOTAL OBJECTIVE SCORE 25 pts _____

*Total Objective Score = (Total Objective Points / Perfect Objective Score) x 25.
iii. Assessment (25 pts) SCORE
1. Physiotherapy Diagnosis 3 pts _____
2. Physiotherapy Prognosis 3 pts _____
3. Focus of Physiotherapy 2 pts _____
4. Prioritized Problem List 5 pts _____
5. Anticipated Problems 4 pts _____
6. Long Term Goals 4 pts _____
7. Short Term Goals 4 pts _____

TOTAL ASSESSMENT SCORE 25 pts _____

iv. Plan (30 pts) SCORE

1. MD Prescribed PT Mx 2 pts _____
2. Physiotherapy Mx 10 pts _____
3. Home Exercise Program 5 pts _____
4. Home Instructions 5 pts _____
5. Referrals 4 pts _____
6. Precautions 4 pts _____

TOTAL PLAN SCORE 30 pts _____

TOTAL IE/RE GRADE 100 pts _____

c. JOURNAL REPORTING (80 pts) SCORE

1. Assessment (40 pts)
a. Problem/Population 10 pts _____
b. Assessment 10 pts _____
c. Comparison 10 pts _____
d. Outcome 10 pts _____
2. Management (40 pts)
a. Population/Problem 10 pts _____
b. Intervention 10 pts _____
c. Comparison 10 pts _____
d. Outcome 10 pts _____

TOTAL JOURNAL REPORTING GRADE 80 pts _____

d. POWERPOINT VISUAL GUIDELINES (10 pts. OR 0 pts.)

o Font Size: > 27
o Font Style: ARIAL
o Maximum of 5 lines PER SLIDE
o Tables font size is >27
o All presenters have a Name Tag > 1.5in x 1in per letter

TOTAL POWERPOINT VISUAL GUIDELINES GRADE 10 pts _____

GROUP GRADE

Total Medical Background Grade = _____ x 0.30 = _____

Total IE/RE Grade = _____ x 0.30 = _____
Total Journal Reporting Grade = _____ / 80 x 30 = _____
Total PowerPoint Visual Guidelines Grade = _____

TOTAL GROUP GRADE (100 pts, 80% of total Case Conference Grade) = _____