Introduction to the Clinical Setting

8/12/2019 Introduction to the Clinical Setting

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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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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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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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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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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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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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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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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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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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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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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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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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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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Introduction to the Clinical Setting

Documents

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