1. Clinical Decision Making Process
EBP

2. Clinical Decision Making Process
Universal Patient Management Guide
Connie Blow, MS, PT Kyle Gibson, PT, MA, OCS
University of Missouri-Columbia
© 2007

3. Components of Clinical Decision Making

4. Examination Documentation Template
Begins with………
Patient Demographics
Reason for Referral
Current Pathoanatomical or Pathophysiological conditions
Past Medical History
Systems Review
Tests and Measures

5. Patient Demographics

6. Demographics Patient Name Date of Birth Chronological Age
Adjusted Chronological Age
Date of Exam
Referring Physician
Other??

7. 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

8. Past Medical History Social 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

9. Systems Review
Identification of issues requiring referrals or consultations
Status of:
Cardiopulmonary
Integumentary
Musculoskeletal
Neuromuscular
Cognitive/Arousal

10. Systems Review Blood Pressure Edema Heart Rate Respiratory Rate
Must memorize normal and exercise values for BP, HR, RR

11. 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”

12. Quick Check
What is the normal blood pressure, heart rate and respiration rate for an 8 month old infant?
Blood Pressure /53-66 mm Hg
Heart Rate bpm
Respiration Rate breaths per minute

13. 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

14. Tests and Measures Reliability Validity Appropriate Population
What are you wanting to measure and why?

15. Quick Check
Where and the categories of tests and measures be found quickly?
Guide to PT Practice

16. 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

17. Components of Clinical Decision Making

18. Evaluation Clinical judgements based on examination data
Identification of Pt. Problems
Organize data through use of disablement model

20. Quick Check
PT Diagnosis is the same as the Practice Patterns found in the Guide to PT Practice.
False

21. 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

22. 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

23. This sounds like a call for a template!

24. 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

25. 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.

26. 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.

27. 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.

29. Determination of the ability to meet Client/Patient Preferred Outcome
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

30. Plan of Care
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

32. 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

34. 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?

35. Quick Check
At what points in the Client Management Model do we base decisions on the best evidence?
Every One!

36. Patient Preference
EBP
Clinical Expertise
Research

37. 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