6
1
Clinical Decision Making
Process
5
2
Universal Patient Management
Guide
4
Connie Blow, MS, PT
Kyle Gibson, PT, MA, OCS
3
University of Missouri-Columbia
© 2007
Components of Clinical Decision Making
6
Examination
5
2
4
3
Examination Documentation
Template
• Begins with………
• Patient Demographics
• Reason for Referral
– Current Pathoanatomical or
Pathophysiological conditions
• Past Medical History
• Systems Review
• Tests and Measures
Patient Demographics
Demographics
Patient Name
Date of Birth
Chronological Age
Adjusted Chronological Age
Date of Exam
Referring Physician
Other??
Reason for Referral
• Client/Patient Preferred Outcome
– Patient’s motivation expected outcome for seeking
services.
– This information encourages the therapist to keep
patient centered examination, intervention and
outcome measurement at the forefront of their minds.
• Current Pathoanatomical or Pathophysiological
Condition
– Gives a medical, anatomical or phathophysiological
context to the examination
Past Medical History
• Health History Questionnaire
• Review of records
Past health status
Current health status
Previous therapeutic interventions and outcomes
Structured Patient/Client Interview
– Red/yellow flags
– Current Medications
– Previous/Current Functional Level
Social History
– Work Status
– Cultural Preferences
Systems Review
• Identification of issues
requiring referrals or
consultations
• Status of:
–
–
–
–
–
Cardiopulmonary
Integumentary
Musculoskeletal
Neuromuscular
Cognitive/Arousal
Systems Review
Blood Pressure
Edema
Heart Rate
Respiratory Rate
Must memorize normal and exercise values for BP, HR, RR
Betty Gail Phenomenon
“I am fine………just a little
dizzy”
“I don’t know…..it’s probably
the weather….what are we
doing first today?
“My sugar this morning? …..it
was OK yesterday afternoon”
“Oh, that bump on my heel?
It’s nothing…..I just have to be
careful when I first stand up on
it”
Quick Check
• What is the normal blood pressure, heart
rate and respiration rate for an 8 month old
infant?
• Blood Pressure 87-105/53-66 mm Hg
• Heart Rate 100-160 bpm
• Respiration Rate 30-60 breaths per minute
Quick Check
• What are four signs of increased ICP in an 8 month old
infant?
•
•
•
•
•
•
•
•
Irritability
Vomiting (projectile)
Sunset Eyes
Increased Tone (change in tone)
Difficult to arouse
Increase Strabismus
Changes in feeding
Seizures
Tests and Measures
• Reliability
• Validity
• Appropriate
Population
• What are you wanting
to measure and why?
Quick Check
• Where and the categories of tests and
measures be found quickly?
• Guide to PT Practice
Categories of Tests and Measures
• Disability
– Ability to fulfill life roles in school, work, recreation,
social
• Functional Status
– Mobility, transfers, play skills, self care
• Impairments
– Pain, ROM, strength, endurance, circulation
• Pathophysiological
– Often same as medical diagnosis
• Disease, trauma, metabolic imbalance
Components of Clinical Decision Making
6
5
Examination
Evaluation
4
3
6
5
Examination
Evaluation
4
PT Diagnosis
Quick Check
• PT Diagnosis is the same as the Practice
Patterns found in the Guide to PT
Practice.
• False
Diagnosis “Guide Language”
“Both the process and the end result of
evaluating examination data, which the
physical therapist organizes into clusters,
syndromes or categories to help
determine the prognosis (including plan of
care) and the most appropriate
intervention strategies.”
APTA Guide to Physical Therapy Practice
Enhanced Mizzou Language
• Statement that minimally links
impairments to functional deficits. Include
pathoanatomical or pathophysiological
classification as it affects prognosis or
plan of care.
– Conclusion of the evaluative process
– Helps determine the prognosis
– Required to develop plan of care
•This sounds like a
call for a template!
Documentation of PT Diagnosis
• “Patient……
• “with an inability to…….(Disability)
• “as a result of difficulty in
performing…(Linking Disability to FL’s)
• “secondary to....... (Linking FL’s to
Impairments)
• “in the presence of signs and symptoms
consistent with specific pathologies
Example
• Patient is a 23 year old male with an
inability to work as a carpenter due to
difficulty reaching/working overhead
secondary to right rotator cuff weakness
with glenohumeral hypomobility. These
impairments are consistent with a
possible right shoulder rotator cuff
impingement and tendonitis.
Model
•
Patient is a 23 year old
male with an inability to
work as a carpenter due to
difficulty reaching/working
overhead secondary to
right rotator cuff weakness
with glenohumeral
hypomobility. These
impairments are consistent
with a possible right
shoulder rotator cuff
impingement and
tendonitis.
•
•
•
•
•
“Patient……
“with an inability
to…….(Disability)
“as a result of difficulty in
performing…(Linking
Disability to FL’s)
“secondary to....... (Linking
FL’s to Impairments)
“in the presence of signs
and symptoms consistent
with specific pathologies IF
it affects prognosis or plan
of care.
Physical Therapy Diagnosis
Key Concepts
 Not the same as PT Practice Pattern
 More than an ICD Code
 Linking…NOT Listing
– Linkage between functional limitations and
impairments always required
– Linking functional limitations to disability is
required when disability is present
– Inclusion of suspected pathoanatomical or
pathophysiological classification is included
as it affects prognosis or plan.
6
5
Examination
Evaluation
Prognosis
PT Diagnosis
Plan of Care
Prognosis
Determination of the ability to
meet Client/Patient Preferred
Outcome
Total Time Needed to Reach
Optimal Level of Functioning
Based on Guide to PT Practice and
Available Evidence
Written as:
Who, Will Do What, Under What
Conditions, How Well, and By When
Long Term Goals/Outcomes:
generally address remediation of
functional limitations & disability
Short Term Goals:
generally address remediation of
impairments that have been linked to FL
Patient Centered
6
Implementation
POC
Examination
Evaluation
Prognosis
PT Diagnosis
Plan of Care
Documentation of Interventions
• Described such that it reflects “skilled PT”
– “Gait training”…..not sufficient
– “Gait training utilizing manual and verbal cues
for proper weight shift and symmetry of stride
length.”
Show link to outcome measures
Evidence based
Specific enough to guide care
Document Patient/Family Consent and
Understanding
Outcomes
Re-examination Examination
Implementation
POC
Evaluation
Prognosis
PT Diagnosis
Plan of Care
Outcome Measures and
Re-examination
Efficacy of Treatment
Goals and Objectives Reasonable?
Appropriate Interventions for Impairments?
Patient Motivation?
Goals Patient Centered?
Constraining Factors?
Discharge?
Revise Goals and Objectives?
Quick Check
• At what points in the Client Management
Model do we base decisions on the best
evidence?
• Every One!
Outcome Measures
Re-examination
Examination
Patient
Preference
Implementation
Plan of Care
Evaluation
Research
Clinical
Expertise
Prognosis
Plan of Care
PT Diagnosis
References
• O’Sullivan SB, Schmitz TJ, Physical
Rehabilitation Assessment and Treatment 4th ed.
Philadelphia, PA 2001
• Guide to Physical Therapist Practice. Rev 2nd
ed. Alexandria, Va: American Physical Therapy
Association;2001
• Using the Guide for Pediatric Practice, Chiarello,
LA October 2000 CSM Presentation
• Quinn L, Gordon J, Functional Outcomes –
Documentation for Rehabilitation. Saunders,
Philadelphia PA 2003