2. clinical decision making

8/10/2019 2. Clinical Decision Making

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Clinical Decision Making


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Lecture outline

Clinical decision making process

APTA model


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Clinical reasoning

Information

Decisions

Actions

Forward reasoning process Backward reasoning process (hypothetic-deductive process)

Hypothesis testing methods

HOAC II (Hypothesis oriented algorithm for clinicians II)

Hypothesis

Clinical decision72 hours


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Models of Disablement

Disease sign symptoms

Impairments direct & indirect

Functional limitation

Disability


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APTA Model of Practice

1. Examination History

Systemic Review

Tests and Measurements

2. Evaluation

3. Diagnosis

4. Prognosis

5. Intervention

6. Reexamine


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5

6

2

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Components of Clinical Decision Making


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2

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Examination

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6

2

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History

Interview/Review of records

Family/Patient expectations anddesired outcomes

Past health status

Current health status

Social history


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Key Questions

Family/Patient

goals

Patientoccupation

Family activitiesand hobbies

Previous Therapies

Patients Progress

Medications, surgeries

Family Attitudes

and Knowledge of

Diagnosis

Available Family

Support Systems


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Systems Review

Identification of issues

requiring referrals or

consultations Status of:

Cardiopulmonary

Integumentary

Musculoskeletal

Neuromuscular


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TESTS AND MEASURES

Content and Development

Validity

Reliability

Sensitivity

Specificity


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Psychometric Properties

Reliability is the consistency or reproducibility of

test measurements. It is the degree of agreement of

the measurements with each other after repeated

tests.

What is test reliability?


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What is Validity?

The degree to which a measure represents what it intends to measure.


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Sensitivity

How well a test identifies people who truly have the

condition measured by the test.

Specificity

How well the test identifies people who doNOT

have the condition being measured.


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Examination

Examination may include the following:

joint mobility

muscle strength

postural alignment

movement patterns

reflexes coordination

balance

endurance

functional performance in ADLs,

home assessment, school sensation

perceptual skills

development of gm and fm skills

other


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Examination

5

6

Evaluation

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Evaluation


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Examination

5

6

Evaluation

PT Diagnosis4


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Examination

5

6

Evaluation

PT DiagnosisPrognosis

Plan of Care


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Components of the Plan of Care

Measurable goals

Functional outcomes Predicted extent of improvement

(Prognosis)

Duration and frequency of intervention

Criteria for discharge

Specific Intervention Strategies


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Goals the remediation of

impairments

OSullivan and Schmitz

reduction or elimination of the

physical signs and symptoms of

pathology and impairments.limiting

the patients functional abilities.

Kisner and Colby

..the intended results of patient/client

management and indicate the changes

in impairments.that are expected

as the result of implementing the plan

of care.

Guide to Physical Therapy

Practice


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Patient Goals Must Be

Developed in collaboration with the patient

Patient centered

Measurable Realistic

Functionally relevant

Linked to each other Specific in the timeframe for completion


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Patient Centered Goals

Determine patients desired outcome of therapy

Require understanding of activities andenvironments

Work

School

Self care

Leisure

Established with the patient to relate to desiredoutcome


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Five Elements of Patient Centered

Goals

By when?

How well? Under whatconditions?

Will Do

What?

Who?

Patient Centered

Functional Goal


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WHO

Is always the patient

in patient-centeredgoals


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WHAT

The activity the patientwill perform

Related to the desired outcomes of therapy

Observable behavior Repeatable

Definite beginning and ending

Avoid will be able toPt. WILL ambulate


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UNDER WHAT CONDITIONS

Incorporates specific elements of a measure

May be distance, time, environmental variables

Must be a relevant measure


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HOW WELL

Defines level of assistance needed

Defines number of successful attempts required

Requires specificity for reliability

Provides the set criterion for achievement


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WHEN

Target date for

achievement of goal

Evidenced based

decision

Dates may change as

therapy progresses


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Sample Goal

WHOSara will

WHAT

ambulate 100 feet

CONDITIONS

with Axillary crutches, NWBing on left, without loss of balance

HOW WELL

twice in two consecutive treatment sessionsWHEN

by March 8 2014.


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Examination

Implementation

POC

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Evaluation

PT DiagnosisPrognosis and

plan of Care


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Therapeutic Exercise

Functional Training

Adaptive Equipment

Wound Care

Gait Training

Patient Education


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Examination

Implementation

POC

Outcomes

Re-examination

Evaluation

PT DiagnosisPlan of Care


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Outcome Measures and

Re-examination

Efficacy of Treatment

Goals and Objectives Reasonable?

Appropriate Interventions for Impairments?

Patient Motivation?

Constraining Factors?

Discharge?

Revise Goals and Objectives?


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Examination

Implementation

Outcomes

Re-examination

Evaluation


Evidenced Based Practice


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Evidenced Based Practice

ResearchClinical Expertise

Patient Preference


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Examination

Implementation

Plan of Care

Outcome Measures

Re-examination

Evaluation


Prognosis

Patient

Preference

ResearchClinical

Expertise

Clinical Decision Making in Physical Therapy


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Three components of Physical

Therapy Intervention Coordination

Communication

Documentation

Patient / client related instruction

Procedural intervention


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Intervention

Restorative

Compensatory

Preventative

FITT

EBP


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Documentation

POMR (problem oriented medical record)

4 phases

Formation of database

Identification of problem Identification of special treatment

Assessment of effective treatment

SOAP


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Clinical decision making

Expert vs Novice

Knowledge base and experience

Cognitive processing style (receptive data gathering vsprocedural)

Self monitoring strategies

Communication and teaching skill


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Thanks

2. clinical decision making

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