Patient Evaluation and Clinical DecisionMaking

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Patient Evaluation and Clinical Decision-Making

• Rehab 536
• Cyndi Robinson
• Cheryl Kerfeld
• http//faculty.washington.edu/cyndirob/rehab536.ht
  ml

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Elements of Patient Management

• Examination (Data Collection)
• History (Subjective)
• Systems Review (Subjective and Objective)
• Tests and Measures (Objective)
• Evaluation (Assessment)
• Problem List
• PT Diagnosis
• Prognosis
• Intervention (Plan)
• Goals
• Treatment Plan
• Follow-up
• Re-examination

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Definitions

• Examination
• The process of gathering data about the
  patient/client
• Evaluation
• A dynamic process in which the PT makes clinical
  judgments based on data gathered during the
  examination.
• Guide to PT Practice, 2001

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Clinical Decision-Making Process

• History
• chart review and interview

Red Flag Refer to physician
Systems Review and Scan Exam
Tests and Measures Posture, palpation,
goniometry, MMT, muscle length tests, functional
tests
Assessment PT diagnosis, problems, disability,
functional limitations, impairments, prognosis
Considerations Precautions Stage of
Healing Disposition Co-morbidities Age
Goals Long Term Short Term
Plan of Care
Re-examination
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APTA Pt/Client Management Worksheet

• What is it?
• Developed from Guide to PT practice
• Guides comprehensive
• Initial examination
• Documentation of initial assessment

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Step 1 Examination

• History (Subjective)
• Systems Review (Subjective and Objective)
• Tests and Measures (Objective)

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Step 2 Analyze the Data

• Identify the problems
• Prioritize the problems

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Step 3 Determine the PT Diagnosis

• Organize the information into defined
• Clusters
• Syndromes
• Categories
• In order to
• Classify dysfunction (NOT disease)
• Plan treatments
• Predict outcomes

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Step 3 PT vs Medical Diagnosis

• The objective of the medical doctor is to either
  diagnose or rule out disease or pathology.
• Physical Therapists use the examination process
  to identify impairments and functional
  limitations that result from pathology or disease.

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Step 3 PT vs Medical Diagnosis

• Medical doctors use labels that identify diseases
  or conditions at the level of the cell, tissue,
  organ or system.
• Physical Therapists use labels that identify the
  impact of a condition on the patients function
  at the level of the system, especially the
  movement system.

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Step 4 Prognosis and Plan of Care

• Prognosis
• Predicted optimal function
• Time required

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Step 4 Prognosis and Plan of Care

• Plan of Care (POC)
• Goals
• Expected outcomes
• Interventions
• Frequency and duration of treatment
• Criteria for discharge

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Step 5 Re-examination

• Outcome measures
• Evaluate progress toward goals
• Treatment plan modification
• Discharge planning
• Patient and family education
• Follow-up care

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APTA Patient/Client Management

• History
• chart review and interview

Red Flag Refer to physician
Systems Review and Scan Exam
Tests and Measures Posture, palpation,
goniometry, MMT, muscle length tests, functional
tests
Assessment PT diagnosis, problems, disability,
functional limitations, impairments, prognosis
Considerations Precautions Stage of
Healing Disposition Co-morbidities Age
Goals Long Term Short Term
Plan of Care
Re-examination
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Patient Examination Patient History and
Interview

• Rehab 536

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Patient Examination History

• A systematic gathering of data from both the past
  and the present - related to why the
  patient/client is seeking services.
• Information is gathered through
• Interview
• Chart Review
• Other sources

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Examination History
Demographic Social Employment Recreation Livin
g environment PMH Health habits Family
history Chief complaint Functional
status Activity level Medications Clinical
diagnostics Pain history
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Patient History and Interview Purpose

• Gather information related to
• Current condition
• Past medical history
• Hypothesis development
• Direct and focus the examination.
• Gather measurable data which can be used to
  establish a baseline for function.
• walking distance
• sleeping duration
• pain level
• Determine the patients goals

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Patient History and Interview Stages

• Preparation- chart review
• Greet, establish rapport
• Invite patients story
• Establish agenda for interview
• Generate and test hypotheses
• Establish shared understanding of problem
• Negotiate plan
• Close

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Patient History and Interview Preparation

• Review the Referral and Medical Record
• medical diagnosis
• diagnostic tests
• referral source
• precautions
• (social history)

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Patient History and Interview General
Considerations

• Introduction
• Assure patient comfort
• Sit or stand at eye level with the patient
• Review the reason for referral
• Provide privacy/confidentiality
• Obtain informed consent to proceed with the
  examination

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Patient History and Interview General
Considerations

• Flexibility in communication style
• Follow a general format
• Listen for red flags
• Be prepared to ask follow-up questions
• Open vs close-ended questions

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Patient History and Interview General
Considerations

• Gather measurable data
• Distance
• Duration
• Time
• Function
• Number (i.e., of falls)

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Patient History and Interview Primary Complaint

• What is the primary problem or complaint?
• Are there related problems?

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Patient History and Interview 7 Attributes of
Symptoms

• Location- Where is it? Does it radiate?
• Quality- What is it like?
• Quantity and Severity- How bad is it?
• Timing- When did (does) it start? How long does
  it last? How often does it occur?
• Setting in which it occurs- Contributing
  circumstances, environmental factors, activities,
  emotional reactions
• Factors that make it better or worse
• Associated manifestations

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Patient History and Interview Onset of
Symptoms

• When?
• Sudden- date of surgery or injury
• Insidious- approximate date symptoms started
• How?
• Sudden- mechanism of injury
• Insidious- contributing activities

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Patient History and Interview Location of
Symptoms

• Where is the pain?
• Point to the area of the pain.
• Has the location of the pain changed?
• Does the pain spread to other areas?
• Draw the pattern on a body chart

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Patient History and Interview Quality of
Symptoms

• Severity? Rate using a pain scale
• 0-10
• Visual Analogue Scale
• Describe the pain sensation
• Sharp
• Dull
• Throbbing
• Aching
• Burning

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Patient History and Interview Behavior of
Symptoms

• Constant or intermittent?
• Frequency of episodes
• Duration of episodes
• What makes the symptoms worse?
• What makes the symptoms better?

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Patient History and Interview Recent Behavior
of Symptoms

• Are the symptoms
• Staying the same
• Getting better
• Getting worse
• Are the frequency of episodes
• Same
• Less often
• More often
• Are the duration of episodes
• Same
• Shorter
• Longer

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Patient History and Interview Diagnostic Tests

• What diagnostic tests have been performed?
• X-ray CT scan
• MRI Bone scan
• EMG Blood test
• What were the results of the diagnostic tests?
• Reported by
• Patient
• Medical office
• Physician

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Patient History and Interview Previous Care

• What
• Hospitalization
• Rehabilitation/Therapy
• Orthotics/Prosthetics
• Chiropractic
• Massage
• Acupuncture
• What treatment was received?
• When- past or current?
• Outcome- is/was it effective?

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Patient History and Interview Past Medical
History (PMH)

• What
• Hospitalizations
• Surgery
• Medical conditions/ co-morbidities
• Injury
• Previous episodes
• When
• Current symptoms, limitations, precautions

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Patient History and Interview Medications

• Related to current condition
• Prescription
• Non-prescription
• Related to other medical conditions
• Prescription
• Non-prescription
• General
• Vitamins, etc

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Patient History and Interview Assistive Devices

• What?
• Hearing Wheelchair
• Visual Railings
• Ambulation Bath bench
• How often?
• When?
• In what circumstances?

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Patient Interview Social History

• Live alone?..... Or with ________?
• Apartment or house?
• Steps to entrance? Railing?
• Steps inside? Railing?
• Daily activities?
• Pets?

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Patient History and Interview Occupation/
Recreation

• Job requirements
• Recreational activities
• Hobbies
• Adaptations needed
• Changes related to current diagnosis

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Patient History and Interview Function Prior
to Onset

• What was your level of function prior to this
  incident or episode?
• Human assistance required?
• Assistive devices?
• Adaptations needed?
• Activity limited due to impairments?

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Patient History and Interview Current Function

• Walking distance
• Sitting tolerance
• Lifting tolerance
• Sleep pattern
• Assistive devices
• Human assistance for ADLs
• Record measurable data

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Patient History and Interview Patients Goals

• What are your goals for PT?
• Patients may require guidance to establish their
  goals