2024 CCI Initial Evaluation Documentation PDF

The Initial Evaluation and Documentation PT 8361 CCI Dr. Hiser, PT, DPT, PhD Dr. Hsu, PT, DPT Dr. Christman, PT, DPT Thanks to Dr. Maring for original slide  Session Goals Review components of the initial evaluation (IE...

The Initial Evaluation and Documentation PT 8361 CCI Dr. Hiser, PT, DPT, PhD Dr. Hsu, PT, DPT Dr. Christman, PT, DPT Thanks to Dr. Maring for original slide  Session Goals Review components of the initial evaluation (IE) and documentation of the IE in the context of the patient client management model. Utilize Guide to PT Practice framework Review/practice specific documentation components of the IE (exam portion).  Documentation and the Initial Evaluation Goal in CCI: Apply documentation principles re: IE Foundations of Interventions will focus on treatment and progress notes. Note writing will be a building process  Will not have all the required tools to perform a complete initial evaluation until later in the curriculum.  We will focus primarily on documentation of the Exam portion of an IE (subjective history, systems review, tests and measures)  Exploring the Guide to Physical Therapist Practice (4.0) Guide to Practice http://guidetoptpractice.apta.org/content/current Reference for IE and documentation framework, components, and definitions The International Classification of Functioning, Disability and Health (ICF) provides a framework for clinical reasoning. (You will cover this more thoroughly in Professional Issues) Therefore, it also provides a framework for the IE and documentation structures.  Structure of the International Classification of Functioning, Disability and Health (ICF) model of functioning and disability In 2008, the APTA House of Delegates endorsed the International Classification of Functioning, Disability and Health, known more commonly as ICF.6 This is a classification of health and health-related domains and is the World Health Organization's (WHO) framework for measuring health and disability at both individual and population levels. This framework informs current physical therapist practice and has been incorporated into all relevant sections of this version of the Guide. © 2014 by American Physical Therapy Association  Elements of the Patient/Client Management Model We will briefly highlight each of these sections! Which components of the patient/client management model do you think would be included in the IE? © 2014 by American Physical Therapy Association  Examination - Overview 3 Components I. History (covering this in both Foundations of Examination as well as the Professional Issues class. Includes symptom investigation as well as a review of systems). Differentiate between a Systems Review and Review of Systems! Review of Systems: Information about all major body systems to determine whether there are symptoms that suggest the need for referral for additional medical evaluation. The physical therapist conducts a review of systems during the history-gathering (subjective) component of examination. II. Systems Review: A brief or limited hands-on 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 individual.  History - The history is a systematic gathering of data—from both the past and the present—related to why the individual is seeking the services of the physical therapist. - The data that are obtained include: - demographic information (e.g., age, education, primary language) - social history (e.g., cultural beliefs and behaviors) - employment and work history - growth and development (e.g., developmental hx, hand dominance) - living environment (e.g., assistive devices/technology, community characteristics) - general health status (e.g., general health perception, mental function, physical function) - social and health habits (past and current) (e.g., behavioral health risks, level of physical fitness) - family history - medical and surgical history - current conditions or chief complaints - functional status and activity level  Review of Systems During the history-gathering phase, physical therapists also seek information about all major body systems to determine whether there are symptoms that suggest the need for referral for additional medical evaluation. This review of systems typically includes reports related to the following: Cardiovascular/pulmonary systems Endocrine system Eyes, ears, nose, or throat Gastrointestinal system Genitourinary/reproductive systems Hematologic/lymphatic systems Integumentary system Neurologic/musculoskeletal systems Systems Review  Examination – Tests and Measures Tests and measures are a component of the physical examination used to: Confirm or reject a clinical hypothesis regarding the factors that contribute to making the individual’s current level of function less than optimal. Support the physical therapist’s clinical judgments about the diagnosis, prognosis, and development of an effective management plan.  Examination – Tests and Measures There are ~26 categories of tests and measures that are part of the physical therapist’s toolbox. The categories are listed in the web version of the new Guide. (Discussed in Professional Issues) Clearly you will not be covering all of those in your introductory course this semester. It is very important to link the selected test to your purpose for conducting the test. That is a critical component of the clinical reasoning process. Tests and measures  Types of Measures Performance-based measures involve observing the individual performing an activity. Self-report measures provide information about the individual's perception of how their impaired body function or structure is limiting activities and participation. Properties of Tests and Measures Validity: The degree to which a Reliability: Consistent time useful (meaningful) interpretation after time, with as little can be inferred from a variation as possible. measurement.  Evaluation The physical therapist goes beyond the Examination in order to: Interpret the person’s response to tests and measures Integrate the tests and measures data with other information collected during the history Determine a DIAGNOSIS/DIAGNOSES amenable to physical therapist management. Determine a PROGNOSIS including goals for physical therapist management Develop a Plan of Care (if indicated) There is NO section of the documentation labelled evaluation. It is an integrative process that includes all the components of Patient/Client Management Model.  Diagnosis Collect and sort data into categories into a classification scheme. The classification scheme must be consistent with the PT’s scope of practice (e.g. PT’s don’t diagnose Muscular Dystrophy but may diagnose the disorder of the movement system associated with Muscular dystrophy). Diagnosis helps direct the treatment options.  Prognosis Determination of predicted optimal level of improvement in function and the amount of time needed to reach that level. Can be influenced by contextual factors Identify realistic, achievable goals and outcomes. More on goals a little later in this session! *You may initially find this step very challenging as student PTs and first couple of years of clinical practice. Your ability to prognosticate will improve with more experience.  Interventions Interventions are based on Examination findings Evaluation and Diagnosis that supports a PT intervention Prognosis associated with maintained or improved health status and, Plan of Care designed to improve, enhance or maximize function. Goals are the intended impact on functioning as a result of implementing a plan of care.  Interventions Factors that influence complexity, frequency, and duration of the intervention and the decision-making process may include: Psychosocial and economic factors. Patient’s overall health status. Adherence to the intervention program.  General Categories of Intervention Patient/Client Instruction/education Respiratory and ventilatory techniques Adaptive and Assistive Technology Biophysical Agents Functional Training Integumentary Repair and Protection Manual Therapy Motor Function Training Therapeutic Exercise  Plan of Care The PT uses the information generated during the encounter to formulate a plan of care (POC). The POC represents the culmination of the examination, diagnostic, and prognostic processes. Requires collaboration with the individual and when appropriate with others. PT analyzes and integrates all the information to determine the plan of care. * Thus, similar to your interventions, the IE will also drive your POC.  Plan of Care (POC) POC includes: Goals and predicted level of optimal improvement (this is according to the Guide to PT Practice – some include this information in the Assessment). Specific interventions to be used. Proposed duration and frequency of the interventions required to reach the goals and outcomes. Anticipates the conclusion of the episode of care Appropriate follow-up or referrals.  Outcomes Outcomes are the actual results of implementing the plan of care. At an individual level, indicates a clinically meaningful outcome that impacts the person’s activity, participation, and health and wellness. Outcome data can also be reported at the population level (e.g. determine institutional effectiveness, research, etc.).  The process of physical therapist patient and client management. - Which parts of the patient client management model are included in the IE? - Which portions of the patient-client management model will be informed by your IE? © 2014 by American Physical Therapy Association  Documenting your Examination and Evaluation Now let’s look at each of the “ingredients” you should document with specific examples for the examination portion of an IE. Different facilities and settings may vary the overall format. Try to stay flexible and remember the important processes and essential elements. Refer also to the Principles of Documentation (APTA) and Documentation Templates.  Documenting your Examination and Evaluation Components of Documentation Exam (Subjective History, Systems Review, Tests and Measures) Evaluation (thought process that may not include formal documentation) Diagnosis/Prognosis Plan of Care including Goals * Assessment statement- your assessment statement will summarize your findings from your IE in a way that helps you justify the need for your physical therapy services.  In Class Activity: Patient Case T. Bower a 59-year-old woman fell playing basketball in the “over 50 league” a 3 months ago. An x-ray confirmed a displaced fracture of the left fibula at the talocrural line. In collaboration with the patient, the orthopedic surgeon decided on a conservative non-surgical approach with non- weightbearing until healing could be confirmed. Union of the fracture was finally confirmed by x-ray 11 weeks after the original injury. Following removal of the short leg cast, the patient had marked atrophy of all lower extremity muscles, pain in the left ankle with any kind of weight bearing and limited active and passive range of motion. Referred to PT by orthopedic surgeon.  In-Class Activity: Interview the patient What questions might you need to ask this “patient” based on what you know belongs in the history? Remember the Review of Systems! How would you document this?  Example Questions: Asks patient for purpose of visit Asks patient to describe symptoms (onset, location, quality) Asks patient to describe behavior of the symptoms (i.e., what makes it worse, better, etc.) Addresses PMH (related to specific injury; individual & family hx of: CA, DM, HTN, Chol, Heart Problems; individual: surgical hx and hospitalizations) * Addresses medications Addresses PLOF Addresses social history (including employment; health risks –e.g., smoking, alcohol, drugs) Addresses stress levels (min, mod, significant, increased recently?) Addresses depression (i.e. are you feeling depressed? Less interest in activities you previously enjoyed?) Addresses home environment Addresses previous treatment Asks about patient’s goals for therapy Informs patient of what is to happen next Concluding questions (open ended)  Subjective History Documentation Contraindications (e.g., positioning, BP parameters) Precautions (e.g., weight bearing, fall risk) History of present illness/Current condition (including chief complaints) Past Medical/Surgical History (and family history) Previous PT Medications Prior level of function Activity & Participation Limitations/Restrictions: What activities can they not perform related to their life roles (work, home, etc.). Work/Social history Personal Factors Environmental factors Goals for PT  Systems Review What are the components/categories of the systems review? What would you assess under each category? How would you document these? System’s Review Documentation  Tests and Measures The history and the System’s Review will allow you to determine which Tests and Measures to perform You need to prioritize the best tests and measures to implement to perform efficient and evidence-based clinical reasoning. What are some potential tests and measures you might perform for this ‘patient’?  Tests and Measures Documentation Tests and Measures (include those relevant to participation restrictions, activity limitations, or impairments). When at all possible, use standardized measures. https://www.sralab.org/rehabilitation-measures Remember baseline information is important Document normal as well as findings outside of normal.  Example: Tests and Measures Documentation * We will review this again as you learn these test and measures in Examinations, and we approach review for SPI and documentation assignments.  Diagnosis and Prognosis Documentation The PT diagnosis should be consistent with what is communicated to 3rd party payers (e.g., ICD 10 codes) the diagnostic label indicates the primary dysfunctions toward which the physical therapist directs intervention Prognosis and overall potential to benefit from physical therapy along with your rationale for why treatment is/is not indicated. Leads to a detailed Plan of Care. Some sources include goals in the POC (e.g. the Guide); some only include goals in the Assessment statements. This will be facility/location dependent.  POC Documentation Statement of frequency and duration of treatment. Plans for care and coordination (referrals, equipment, consults, etc.). Patient/caregiver related instructions. Direct Interventions Plans for conclusion of the treatment Note that discharge planning starts at the entry-point!  Goals Documentation Goals must be measurable and relate to participation restrictions and activity limitations (either directly or by linking specifically and directly – directly is preferred). Must include the “actor” (e.g. the person), the target behavior including the conditions, the degree, and the expected time. (ABCDE- more in Interventions and CCIV) In 2 weeks, Mr. Smith will walk independently 1000 feet on level surfaces with a cane in right hand (distance between room and dining room).  Assessment Statement Assessment Summary statement Physical therapy impression (note this is not always included in the samples included in your text). Can take several forms. A common approach is to synthesize the participation restriction/ activity limitation with the relevant impairment(s). May be descriptive! e.g. Patient is unable to walk independently secondary to decreased balance and generalized lower extremity weakness. OR: Child is unable to ring sit independently during circle time secondary to poor trunk control and limited hip abduction range of motion.  Re-examination Must include: Selected components of the examination that provide the necessary information to update the patient’s/client’s functional status. Interpretation of the findings and when indicated a revision of goals. When indicated a revision of the plan of care as directly correlated with the documented goals.  Discharge/Discontinuation Summary Discharge is also a type of evaluation. Should include: Current physical/functional status Degree of goals achieved and if not achieved reasons why they were not achieved. Discharge/Discontinuation plans. For example: Home program Referrals Recommendations Caregiver training Equipment Discharge Planning Begins at the Beginning What if it appeared, based on your evaluation, that Mr. Smith would not achieve independence on stairs. What types of considerations would have to go into discharge planning?  Important Components to Include Don’t forget in your documentation to include: Beginning: Patient Name Patient DOB Date of Service Reason for Referral At Conclusion Your Signature, SPT  Documentation Assignments 2 Documentation Assignments: First assignment follows the first SPI review class session (10% of grade; feedback will be provided to assist you in prep for SPI) Second assignment you will document your findings from the SPI (ie the exam portion of the eval- subjective history, SR, and T&M). This will be completed immediately following your SPI using BB/respondus. Questions?