Clinical Reasoning and Patient Centered Care in Physiotherapy

Puan Ruzita Razlan

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Presentation Objectives students will be able to..

• Define clinical reasoning and patient centered care

• Identify important terms related to clinical reasoning and patient centered care

• Have some idea on the basic knowledge and cognitive skill in physiotherapy

• Aware on the importance of clinical reasoning and documentation on the management of patient

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Clinical reasoning

• Clinical reasoning is the process by which a therapist interacts with a patient,collecting information,generating and testing hypotheses,and determining optimal diagnosis and treatment based on the information obtained.

• It has been defined”an inferential process used by practitioners to collect and evaluate data and to make judgments about the diagnosis and management of patient problems

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Clinical reasoning:process

• Clinical reasoning is” the sum of the thinking and decision-making processes associated with clinical practice”

• During this process, the therapist analyses multiple variables contributing to the patient’s limited physical capacity(the ability to execute a task or action in a standard environment) and performance(what the patient can do in his or her own current environment)

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Clinical reasoning:process

• The key elements of the process include generation of hypotheses of factors assumed to underlie the limitations of physical capacity and performance and postulation of the magnitude of those factors.The therapist interacts with the patient and other persons involved in the patient care(family,other

• All decisions and actions need to be made in line with professional ethics and community expectations.

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Terms

• Hypotheses-an assumption or concession made for the sake of argument-an interpretation of a practical situation or condition taken asthe ground for action.• Diagnosis-the process of determining the nature of disorder by considering the patient’s sign and symptoms, medical background and when necessary results of laboratory tests and X-ray examination etc.• Inferential:of,pertaining to,by,or dependent upon inference• Variables:apt or liable to vary or change;changeable:• Execute:to carry out;accomplish:to execute a plan or order./to perform or

do• Postulation:to ask,demand or claim/to claim or assume the existance or

truth of,especially as a basis for reasoning or arguing/to assume without proof,or as self-evident;take for granted.

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Patient-centered care

• Patient-centered care:active involment of patients and their families in the design of new care models and in decision making about individuals options for treatment

• The IOM(Institute of Medicine) defines patient-centered care as:Providing care that is respectful of and responsive to individual patient preferences,needs,and values,and ensuring that patintvalues guide all clinical decisions.

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Patient-centered care

• Patient-centered care is also one of the overreaching goals of health advocacy,in addition to safer medical systems and greater patient involvement in healthcare delivery and design

• Given that non-consumer stakeholders often don’t know what matters most to patients regarding their ability to get and stay well,care that is truly patient-centered cannot be achieved without active patient engagement at every level of care design and implementation.

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Important terms

• Respectful: full of characterised by, or showing politeness or deference

• Resposive:responding especially readily and sympathically to appeal,efforts,influences,etc

• Values:relative worth,merit or importance• Advocacy:the act of pleading for,supporting,or

recommending;active espousal• Stakeholders:a party that has an interest in an enterprise

or project.The primary stakeholders in a typical corporation are its investors,empolyees,customers and suppliers.However,modern theory goes beyond this conventional notion to embrace additional stakeholders such as the community,government and trade associations.

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Clinical reasoning and patient centered care in physiotherapy

• Clinical reasoning in Physiotherapy is characterised as a context-dependent way of thinking and decision making in professional practice to guide practice actions

• This could include the act of making a diagnosis, the decisions related to management issues, as well the ways clinicians use to establish interaction with their patients or to promote their collaboration

• The use of these different strategies allows the clinician and the patient to develop a more informed position about the clinical problem and facilities the establishment of a reciprocal relationship allowing the patient’s experience to be integrated into decisions related to the health care provided.

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Clinical reasoning and patient centered care in physiotherapy-cont.

• The clinicians’ capability to use clinical reasoning and incorporate the patient experience is closely related to the notion of patient-centered practice

• This approach to practice and reasoning involves valuing the individual needs and rights of patients, understanding patients’ illness and health care experience and embracing them within effective relationship that enable patients to participate in clinical reasoning

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Cognitive skill

• Cognitive functioning is a term referring to a human’s ability to process thoughts that should not deplete on a large scale in healthy individuals

• Cognition mainly refers to things like memory, the ability to learn new information, speech,understanding of written material.

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SOAPIER

• S=Subjective Assessment• O=Objective Assessment• A=Analysis/Diagnosis• P=Plan of treatment• I=Intervention• E=Evaluation• R=Review

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The origin of SOAPIER

• Introduced by Dr.Lawrence(SOAP) as a part of organizing the medical record called problem-oriented medical record(POMR)

• Physiotherapist in Malaysia have adapted the original SOAP format into practical tool.

• S=Subjective,O=Objective,A=Assessment,P=Plan

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Subjective assessment

• Medical record• Interview with patient/family/caregivers

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Medical record

• Doctor’s diagnosis and date of even• Symptoms on admission and after the admission• Other significant medical problems(past medical

history)• Risk factors of the disease• Relevant social history-smoking,alcohol,drug

used,lifestyle,support mechanism• Currents medications• Investigation-radiographic studies,clinical laboratory

data,ECG,pulmonary function test,ABG (arterial blood gases) and other diagnostic test.

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Medical record

• Surgical procedure• Other therapeutic regime• Vital sign• Occupational history• Home environment

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Interview

• Purpose:to gather important information about• Patient’s present complain• h/o medical problems• Report of symptoms,risk factors,perception• Understanding of the problem,family situation• Goal for physiotherapy treatment or

rehabilitation

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Objective assessment

• Observation• Palpation• Physical examination:according to patient’s

problem e.g.:auscultation,range of movement,muscle power,muscle tone and etc.

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Analysis

• Diagnosis of patient’s problem according to subjective and objective assessment findings

• Use clinical reasoning concept:the sum of the thinking and decision-making processes associated with clinical practice

• E.g.-Reduce range of all movement of the right shoulder

due to pain and inactivity post immobilization.-Accumulation of secretion at both basal of the lungs

due to infection and ineffective coughing tecnhique.

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Plan of treatment

• According to analysis finding and don’t forget• Patient-centered care:active involvement of

patients and their families in the design of new care models and in the design of new care models and in decision-making about individual options for treatment.

• E.g. pain relief,joint mobilization,mobilising exercise, strengthening exercise

• Airway clearance technique.

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Intervention

• Still need patient-centered care:active involvement of patients and their families in the design of new care models and in decision-making about individual options for treatment

• E.g. of intervention• Trancutaneous Electrical Nerve

stimulation(TENS):modulation mode for 20 minutes.

• Joint mobilibzation:PA,AP and inferior glide grade 1-2

• Autopulley of the shoulder• KIV:theraband exs• Active cycle breathing tachnique(ACBT).

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Evaluation

• To judge or assess the worth of;appraise • Synthesis ans discussion of clinical finding

including the diagnosis(problem) and prognosis(improvement).

• E.g. pain on the right shoulder has reduced by 20% and range of movement improved as tabled below…after treatment..

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Review

• To look over,study or examine again• To consider retrospectively;look back on e.g.-to see patient 2 more days in a row

-to continue with TENS until patientcan manage the pain -to progress joint mobilization tech. to grade 3 as patient tolerance. -to start strenghening exercise using light theraband.

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The purpose of documentation

• Ensure the rights of physiotherapist and the patient are protected should any question arise regarding the care provided to patient.Considered as legal documents and the medical record.

• Method of communicating with other physiotherapist and all other health care professionals.

• Third party players.• Discharge planning/additional care.

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The purpose of documentation

• Help phsyotherapist to organize the thought process in patient care for clinical decision making.

• Used for quality assurance and improvement purposes

• Can be used in outcome research.

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Important note

• Documentation is important as to the patient care process as the assessment,examination,evaluation and patient intervention.

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Discussion

55 year old man is referred to physiotherapy due to having difficulty in breathing-explain why thorough assessment is important for this

patient-state possible information you can extract from his

medical record.-explain the purpose of interviewing this patient?-evaluate possible findings when you examine the patient.