Clinical Decision Making Process

Universal Patient Management Guide

Connie Blow, MS, PTKyle Gibson, PT, MA, OCS

University of Missouri-Columbia

© 2007

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Examination

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Components of Clinical Decision Making

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

DemographicsPatient 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 recordsPast health statusCurrent health statusPrevious 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

Examination

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Evaluation

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Components of Clinical Decision Making

Examination

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Evaluation

PT Diagnosis4

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.

Examination

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Evaluation

PT DiagnosisPrognosis

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 & disabilityShort Term Goals:

generally address remediation of impairments that have been linked to FL

Patient Centered

Examination

ImplementationPOC

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Evaluation

PT DiagnosisPrognosis

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 measuresEvidence basedSpecific enough to guide careDocument Patient/Family Consent and

Understanding

Examination

ImplementationPOC

OutcomesRe-examination

Evaluation

PT DiagnosisPrognosis

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!

Examination

ImplementationPlan of Care

Outcome MeasuresRe-examination

Evaluation

PT DiagnosisPlan of Care

Prognosis

Patient Preference

ResearchClinical

Expertise

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