Chapter 3: PT clinical practice Flashcards
PT duties
- Interpretation of referrals when available
- Initial examination, evaluation, diagnosis, and prognosis (intervention and outcomes)
- Development or modification of a plan of care (POC) based on initial examination/re and which includes the physical therapy goals and outcomes
- Determination of when the expertise and decision-making capability of the PT requires the PT to personally render physical therapy interventions and when it may be appropriate to utilize the PTA
Purpose of the guide (9)
- Describe PT practice
- Outline PT/PTA roles in variety of settings/practices
- Describe settings where PT is practiced
- Standardize PT terminology
- Review edu of PT/PTAs
- Delineate the clinical decision-making process that occurs as part of patient and client management
- Describe examination and evaluation processes including tests and measures
- Describe interventions and the process of choosing appropriate interventions
- Describe utilization of outcome measures
Patient vs. client
Patient: individual who receives health care services including physical therapy direct intervention
Client: an individual not necessarily sick or injured but who can benefit from a PT’s consult, professional advice, or services
Six elements of patient/client management
- Examination
- Evaluation
- Diagnosis
- Prognosis
- Interventions
- Outcomes
Examination
Process of gathering subjective and objective data about patient/client. Comprehensive screening and specific testing process leading to diagnostic classification or referral to another practioner
- patient/client history - system review - test/measures
Evaluation
Clinical judgments based on data gathered during examination. Results determine diagnosis, prognosis, and interventions. Reflects severity of current problem presence of pre-existing conditions, possibility of more than one site involvment, and stability of condition
Subjective data
Data collected by patient report, cant necessarily be measured
Objective data
Not opinion, measure and tested results
Diagnosis
Identification of nature of the illness or problem by examination of symptoms. Describes systems affected by alteration in function. Identify specific patient complaint and overall effect on the person
Medical diagnosis
Determined by physician who identifies an illness or disorder in a patient through an interview, physical examination, medical tests, etc. Parkinson’s vs. difficulty functioning. Disc herniation vs. lower back pain/ difficulty moving
Physical therapy diagnosis
End result of evaluating information obtained from the examination, which the PT uses to help determine the most appropriate intervention strategies. Does not necessarily match medical
How medical diagnosis = functional limitation
Prognosis
Predicted optimal improvement in function and amount of time needed to reach that level. Physical therapist’s realistic expectation of patient’s recovery
Interventions
Skilled techniques and activities that make up treatment plane. Specific or broad. Can involve other professions. Altered in accordance with changes in response/status of patient
Discharge
Process of discontinuing interventions in a single episode of care. PT decides patino no longer requires services or patient wants to stop. No further progression towards goal OR the PT determines that patient/client will no longer benefit from therapy
Outcomes
Actual functional activity achieved by patient. Measurable pre vs post intervention outcomes
Patient/client history
Past/current health status collected from all interested parties, not just patient/client
