Post on 03-Jun-2018
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Introduction to theClinical Setting
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Physical Therapists and WhatThey Do(APTAs Guide to Physical Therapist Practice)
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Clinical Specialist
Is a physical therapist that has advanced
clinical practice competency with a
certificate awarded by the specialty-
regulating body of the professional
association in any of the specialty areas
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Specialty Areas
Cardiovascular and Pulmonary PhysicalTherapy
Clinical Electrophysiology
Geriatric Physical Therapy
Neurologic Physical Therapy
Orthopedic Physical Therapy
Pediatric Physical Therapy
Sports Physical Therapy
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Practice Settings
Physical therapists practice in a broad
range of inpatient, outpatient, and
community-based settings, includingthe following:
Hospitals (critical care, intensive care, acute
care, and sub-acute care)Outpatient clinics or offices
Rehabilitation facilities
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Patients and Clients
Patients
Individuals who are the recipients of
physical therapy examination, evaluation,diagnosis, prognosis, and intervention
and who have a disease, disorder,
condition, impairment, functionallimitation, or disability
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Clients
Individuals or organizations (e.g.
businesses, school systems, athleticteams) who engage the services of a
physical therapist and who can benefit
from the physical therapists consultation,interventions, professional advice,
prevention services, or services
promoting health, wellness and fitness
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Generally accepted elements of
patient/client management typically
apply to both patients and clients
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Scope of Practice
Physical Therapy
The care and services provided by or
under the direction and supervision of aphysical therapist
Physical Therapists (PTs)
The only professionals who provide
physical therapy
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Provide prevention and promote health,
wellness, and fitness
Consult, educate, engage in criticalinquiry, and administrate
Direct and supervise the physical therapy
service, including support personnel
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Roles in Primary Care
Physical therapists have a major
role to play in the provision of
primary care, which has beendefined as:
The provision of integrated, accessible health
care services by clinicians who are accountablefor addressing a large majority of personal
health care needs, developing a sustained
partnership with patients, and practicing within
the context of family and community
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APTA has endorsed the concepts of
primary care set forth by the
Institute of Medicines Committee
on the Future of Primary Care,
including the following:
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Primary care can encompass myriad
needs that go well beyond the capabilities
and competencies of individualcaregivers and that require the
involvement and interaction of varied
practitioners
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Primary care is not limited to the first
contact or point of entry into the health
care systemThe primary care program is a
comprehensive one
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Acute musculoskeletal and
neuromuscular conditions
Certain chronic conditions
Industrial and workplace settings
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Roles in Secondary and Tertiary
Care
Secondary care settings
Patients with musculoskeletal, neuromuscular,
cardiovascular/pulmonary, or integumentarydisorders may be treated initially by another
practitioner and then referred to physical
therapists for secondary care in a wide range of
settings, including acute care and rehabilitationhospitals, outpatient clinics, home health, and
school systems
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Tertiary care settings
Physical therapists provide tertiary care in
highly specialized, complex, and technology-based settings (e.g. heart and lung transplant
units, burn units) or in response to other health
care practitioners requests for consultation and
specialized services (e.g. for patients withspinal cord lesions or closed-head trauma)
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Roles in Prevention and in the
Promotion of Health, Wellness,
and FitnessThese initiatives decrease costs by
helping patients/clients:
Achieve and restore optimal functionalcapacity
Minimize impairments, functional
limitations, and disabilities related tocongenital and acquired conditions
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Maintain health (thereby preventingfurther deterioration or future illness) and
Create appropriate environmentaladaptations to enhance independentfunction
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Physical therapists are involved in:
Prevention
Promoting health, wellness, and fitness
Performing screening activities
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Prevention
Three types of prevention in which
physical therapists are involved: Primary prevention
Secondary Prevention
Tertiary Prevention
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Primary prevention Preventing a target condition in a susceptible or potentially
susceptible population through such specific measures as
general health promotion efforts
Secondary Prevention Decreasing duration of illness, severity of disease, and
number of sequelae through early diagnosis and prompt
prevention
Tertiary Prevention Limiting the degree of disability and promoting
rehabilitation and restoration of function in patients with
chronic and irreversible diseases
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Prevention screening
Physical therapists conduct screenings to
determine the need for: Primary, secondary, or tertiary prevention
services
For further examination, intervention, orconsultation by a physical therapist or
Referral to another practitioner
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Candidates for screening generally are
not patients/clients currently receiving
physical therapy servicesScreening is based on a problem-focused,
systematic collection and analysis of data
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Prevention activities and health,
wellness, and fitness promotion
activities
Exercise programs to prevent or reduce
the development of sequelae in
individuals with life-long conditions
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Other Professional Roles of the
Physical Therapist
Consultation
Education
Critical Inquiry
Administration
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Consultation
The rendering of professional or expert
opinion or advice by a physical therapist
Patient-related consultation & Client-
related consultation
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Education
The process of imparting information or
skills and instructing by precept,example, and experience so that
individuals acquire knowledge, master
skills, or develop competence
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Administration
The skilled process of planning,
directing, organizing, and managinghuman, technical, environmental, and
financial resources effectively and
efficiently
Th Ph i l Th S i
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The Physical Therapy Service:
Direction and Supervision of
PersonnelDirection and supervision are
essential to the provision of high-
quality physical therapy
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The degree of direction and
supervision necessary for ensuring
high-quality physical therapydepends on many factors, including:
Education, experience, and
responsibilities of the parties involved
Organizational structure in which the
physical therapy is provided
A licable state law
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Director of the Physical TherapistService
A physical therapist who hasdemonstrated qualifications based onclinical education and experience in thefield of physical therapy and who has
accepted the inherent responsibilities ofthe role
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Director of the Physical Therapist
Service
Responsibilities of the director of the physicaltherapy service:
Establish guidelines and procedures that will
delineate the functions and responsibilities of all
levels of physical therapy personnel in the serviceand the supervisory relationships inherent to the
functions of the service and the organization
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Director of the Physical TherapistService
Ensure that the objectives of the service are
efficiently and effectively achieved within theframework of the stated purpose of theorganization and in accordance with safe
physical therapist practice
Interpret administrative policies Act as liaison between line staff and
administration
Foster the professional growth of the staff
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Director of the Physical Therapist
Service
Also has responsibilities borne solely byphysical therapists
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Physical Therapist
When the physical therapist directs
assistive personnel to perform specificcomponents of physical therapy
interventions, that physical therapist
remains responsible for supervision of theplan of care
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Physical Therapist
Regardless of the setting in which the
service is given, the followingresponsibilities must be borne solely by a
physical therapist:
Interpretation of referrals when available Initial examination, evaluation, diagnosis,
and prognosis
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Physical Therapist
Development or modification of a plan of
care that is based on the initial examinationor the re-examination and that includes
physical therapy anticipated goals and
expected outcomes
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Physical Therapist
Determination of:
When the expertise and decision-makingcapability of the physical therapist requires the
physical therapist to personally render physical
therapy interventions and
When it may be appropriate to utilize thephysical therapist assistant
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Physical Therapist
Provision of physical therapy interventions
Re-examination of the patient/client in lightof the anticipated goals and expected
outcomes, and revision of the plan of care
when indicated
Establishment of the discharge plan and
documentation of discharge summary/status
Oversight of all documentation for services
rendered to each patient
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Assistive Personnel
Person(s) who may assist the physical
therapist either in selected components ofintervention or some other aspect of the
overall care of a patient
Physical Therapist Assistants (PTAs) Physical Therapy Aides (PT Aides)
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Other Assistive Personnel
Persons licensed or certified in another
discipline but who are employees in aphysical therapy service under thesupervision of a physical therapist
massage therapists
exercise physiologists
athletic trainers
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Introduction
APTAs Guide to Physical Therapist
Practice
Also known as the GuideAPTA developed the Guide as a resource not
only for physical therapist clinicians, educators,
researchers, and students, but for health care
policy makers, administrators, managed care
providers, third-party payers, and other
professionals
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The Guide serves the following purposes:
To describe physical therapist practice in general,
using the Disablement Model as the basis
To describe the roles of physical therapists in
primary, secondary, and tertiary care; in prevention;
and in the promotion of health, wellness, and fitness
To describe the settings in which physical therapists
practice
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The Guide serves the following purposes:
To standardize terminology used in and related to
physical therapist practice
To delineate the tests and measures and the
interventions that are used in physical therapist
practice
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The Guide serves the following purposes:
To delineate preferred practice patterns that will
help physical therapists:
Improve quality of care
Enhance the positive outcomes of physical therapy
services
Enhance patient/client satisfaction
Promote appropriate utilization of health care services Increase efficiency and reduce unwarranted variation in
the provision of services, and
Diminish the economic burden of disablement through
prevention and the promotion of health, wellness, and
fitness initiatives
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The Guide does not provide specific protocols
for treatments, nor are the practice patterns
contained in the Guide intended to serve as
clinical guidelines
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The preferred practice patterns in the Guide
identify the breadth of physical therapist
practice
These are the boundaries within which the physical
therapist may select and implement any of a number
of clinical alternatives based on consideration of a
wide variety of factors, including:
Individual patient/client needs
The professions code of ethics and standards of practice
Patient/client age, culture, gender, roles, race, sex, sexual
orientation, and socioeconomic status
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The Guide is not intended to set forth the
standard care for which a physical therapist
may be legally responsible in any specific case
P f d P i P i
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Preferred Practice Patterns in
Physical Therapy
Found in APTAs Guide to Physical
Therapist Practice (all editions and
revisions)
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Examination
Required prior to the initial intervention and is
performed for all patients/clients
Initial examination is a comprehensive screening
and specific testing process leading to diagnostic
classification or, as appropriate, to a referral to
another practitioner
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Examination
Components:
History
Systems Review
Tests and Measures
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Examination
Components:
History
Systematic gathering of datafrom both the past andthe presentrelated to why the patient/client is
seeking the services of the physical therapist
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Examination
Components:
Systems Review
A brief or limited examination of:
1. The anatomical and physiological status of the
cardiovascular/pulmonary, integumentary,
musculoskeletal, and neuromuscular systems and
2. The communication ability, affect, cognition,
language, and learning style of the patient/client
The physical therapist especially notes how these affect the ability
to initiate, sustain, and modify purposeful movement for
performance of an action, task, or activity that is pertinent to
function
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Examination
Components:
Systems Review
Also assists the physical therapist in identifyingpossible problems that require consultation with or
referral to another provider
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Examination
Components:
Tests and Measures
The means of gathering data about the patient/client
From the history and systems review, the physical
therapist determines patient/client needs and generates
diagnostic hypotheses that may be further investigated
by selecting specific tests and measures
These are used to:
1. Rule out causes of impairment and functional
limitations
2. Establish a diagnosis, prognosis, and plan of care
3. Select interventions
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Evaluation
Are clinical judgments of the physical therapist that
are based on the data gathered from the examination
that are synthesized to establish the diagnosis,prognosis, and plan of care
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Diagnosis
Diagnostic labels
May be used to describe multiple dimensions of the
patient/client, ranging from the most basic cellular level tothe highest level of functioningas a person in society
Typical physician diagnostic labels
Identification of a disease, disorder, or condition at the
level of the cell, tissue, organ, or system
Physical therapist diagnostic labels
Identification of the impact of a condition on function at
the level of the system (especially the movement system)
and at the level of the whole person
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Prognosis (including the Plan of Care)
Prognosis
The determination of the predicted optimal level of
improvement in function and the amount of time needed toreach that level
May also include a prediction of levels of improvement
that may be reached at various intervals during the course
of therapy
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Prognosis (including the Plan of Care)
Plan of Care
Consists of statements that specify the anticipated goals
and expected outcomes, predicted level of optimalimprovement, specific interventions to be used, and
proposed duration and frequency of the interventions that
are required to reach the anticipated goals and expected
outcomes
Therefore describes: Specific patient/client management
Timing for patient/client management for the episode
of physical therapy care
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Intervention
The purposeful interaction of the physical therapist
and the patient/client and, when appropriate, with
other individuals involved in patient/client care,using various physical therapy procedures and
techniques to produce changes in the condition that
are consistent with the diagnosis and prognosis
Components: Coordination, Communication, and Documentation
Patient/Client-related Instruction
Procedural Interventions
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Re-examination
The process of performing selected tests and
measures after the initial examination toevaluate progress and to modify or redirect
interventions
May be indicated more than once during a
single episode of care
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Re-examination
May also be performed over the course of a
disease, disorder, or condition, which for somepatients/clients may be over the life span
Indications for re-examination:
New clinical findings
Failure to respond to physical therapy interventions
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Global Outcomes
Throughout the entire episode of care, the
physical therapist determines the anticipatedgoals and expected outcomes for each
intervention
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Global Outcomes
Beginning with the history, the physical
therapist identifies: Patient/client expectations
Perceived need for physical therapy services
Personal goals and
Desired outcomes
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Global Outcomes
The physical therapist then considers whether
these goals and outcomes are realistic in thecontext of the examination data and the
evaluation
In establishing a diagnosis and a prognosis and
selecting interventions, the physical therapistasks the question,
What outcome is likely, given the diagnosis?
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Global Outcomes
The physical therapist may use re-examination
to determine whether predicted outcomes arereasonable and then modify them as necessary
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Global Outcomes
The physical therapist engages in outcomes
data collection and analysisthat is, thesystematic review of outcomes of care in
relation to selected variables (e.g. age, sex,
diagnosis, interventions performed)and
develops statistical reports for internal orexternal use
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Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Care Consists of all physical therapy services that are:
Provided by a physical therapist
Provided in an unbroken sequence and
Related to the physical therapy interventions for a given
condition or problem related to a request from the
patient/client, family, or other provider
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Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Care May include transfer between sites within or across
settings or reclassification of the patient/client from
one preferred practice pattern to another
Reclassification may alter the expected range of number of
visits and therefore may shorten or lengthen the episode of
care
If reclassification involves a condition, problem, or request
that is not related to the initial episode of care, a new
episode of care may be initiated
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Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Care A single episode of care should not be confused
with multiple episodes of care that may be required
by certain individuals who are classified in
particular patterns
For these patients/clients, periodic follow-up is needed
over a lifetime to ensure optimal function and safety
following changes in physical status, caregivers, the
environment, or task demands
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Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Maintenance A series of occasional clinical, educational, and
administrative services related to maintenance of
current function
No defined number or identified range of number ofvisits is be established for this type of episode
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Episode of Care, Maintenance, or
Prevention
Episode of Physical Therapy Prevention A series of occasional clinical, educational, and
administrative services related to prevention, to the
promotion of health, wellness, and fitness, and to the
preservation of optimal function
No defined number or identified range of number of
visits is be established for this type of episode
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Criteria for Termination of Physical
Therapy Services
Discharge The process of ending physical therapy services that
have been provided during a single episode of care,
when the anticipated goals have been achieved
Does not occur with a transfer that is when thepatient is moved from one site to another site within
the same setting or across settings during a single
episode of care
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Criteria for Termination of Physical
Therapy Services
Discharge There may be facility-specific or payer-specific
requirements for documentation regarding the
conclusion of physical therapy services as the
patient moves between sites or across settings
during the episode of care
Occurs based on the physical therapists analysis of
the achievement of anticipated goals and expected
outcomes
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Criteria for Termination of Physical
Therapy Services
Discharge For patients/clients who require multiple episodes of
care, periodic follow-up is needed over the life span
to ensure safety and effective adaptation following
changes in physical status, caregivers, environment,
or task demands
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Criteria for Termination of Physical
Therapy Services
Discharge In consultation with appropriate individuals, and in
consideration of the anticipated goals and expected
outcomes, the physical therapist plans for discharge
and provides for appropriate follow-up or referral
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Criteria for Termination of Physical
Therapy Services
Discontinuation The process of ending physical therapy services that
have been provided during a single episode of care,
when:
The patient/client, caregiver, or legal guardian declines to
continue intervention
The patient/client is unable to continue to progress toward
anticipated goals and expected outcomes because of
medical or psychosocial complications or because
financial/insurance resources have been expended
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Criteria for Termination of Physical
Therapy Services
Discontinuation When termination of physical therapy services occur
prior to achievement of anticipated goals and
expected outcomes, patient/client status and the
rationale for discontinuation are documented
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Criteria for Termination of Physical
Therapy Services
Discontinuation In consultation with appropriate individuals, and in
consideration of the anticipated goals and expected
outcomes, the physical therapist plans for
discontinuation and provides for appropriate follow-
up or referral
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