PO 001.02. The Physical Therapist Technician will understand and be able to perform the following medical administrative tasks: ◦ Receive a patient.

Provison of Medical Administration

PO 001.02

The Physical Therapist Technician will understand and be able to perform the following medical administrative tasks:◦ Receive a patient on arrival

◦ Create patient charts

◦ Chart documentation

◦ Complete post-treatment procedures

Learning Objectives

PTTs will also be able to explain and apply:◦ The concept of informed consent and it’s

importance

◦ The use of outcome measures

◦ The prioritization of patient referrals to PT

◦ Referral paperwork for required orthoses or clinic transfers

◦ Patient discharges accordingly

Continued . . .

INFORMED CONSENT

Consent by a patient to undergo or participate in a medical treatment after the patient understands the risks involved

Informed consent allows the patient to participate in choices about their health care

In order for the patient's consent to be valid, they must be considered competent to make the decision at hand and consent must be voluntary

Informed Consent

It is generally accepted that complete informed consent includes a discussion of the following elements:◦ The nature of the decision/procedure ◦ Reasonable alternatives to the proposed

intervention ◦ The relevant risks, benefits, and uncertainties

related to each alternative ◦ Assessment of patient understanding ◦ The acceptance of the intervention by the patient

Elements of Informed Consent

WCPT requires that PTs shall inform the patient/client verbally, and where required, in writing of the nature, expected duration and cost of intervention/treatment prior to the performance of such activities

The physical therapist shall document in the clinical notes when consent is received, implied or expressed. Once consent has been received, the intervention/treatment plan may be instituted

WCPT and Informed Consent

Patients, wherever possible, are given information as to the PT treatments proposed, so that the patient is:

◦ Aware of the findings of the examination/assessment

◦ Given an opportunity to ask questions and discuss with the PTT the preferred interventions/treatments, including any significant side effects

Patient Informed Consent

◦ Given the opportunity to decline particular modalities in the plan of intervention/treatment

◦ Given the opportunity to discontinue intervention/treatment

◦ Encouraged to be involved in the examination/assessment process and to volunteer information that may have a bearing on the physical therapy program

Continued . . .

If after the PTT describes the intended treatment and the patient decides that they are not comfortable or do not want that specific treatment then:◦ The patient is not treated◦ The PTT can come up with an alternative

treatment plan to present to the patient◦ The refusal of treatment needs to be recorded in

the patient’s chart

What Happens if the Patient Does Not Give Informed Consent?

PT REFERRALS

Referrals to the physical therapy department will come from a doctor

The patient will arrive at the PT department with their referral paperwork

The patient will then either be seen immediately if a senior PT tech is available or;

PT Referral Process

The patient will be assigned a priority and an appointment will be scheduled accordingly

The initial assessments of patients will be carried out by a senior PT tech

After a treatment plan is prescribed by the senior PTT, the patient will be given to a junior PTT to conduct the treatment

PT Referral Process Continued . . .

PT Referral Form

When a patient presents for an initial assessment, the PT tech is responsible for the following:◦ Accepting referral paperwork◦ Assigning a priority to the patient◦ Creating a patient chart◦ Selecting the appropriate outcome measure tool◦ Scheduling the appointment◦ Logging the patient into the referral log book◦ Have the patient complete the appropriate

baseline function assessment

Initial Assessment Process

When patients arrive to the PT department with a referral form, the PTT tech that accepts the paperwork needs to record the patient’s information in the admission book

This is a document that is held in the PT department that is used to keep record of the patients and services provided

It is important to filled out the admission book for all patients to ensure there is an accurate reflection of the case load at the PT department

Referral Admission Book

Admission Log Book

Upon presentation of a new PT referral, the PTT should ensure that the patient is screened for general musculoskeletal conditions

This can be done with a generic form given to all patients when the first arrive to the PT department

This form should be included in the patient’s chart and accessible for the PTT who will verify the patient doesn’t have any general contraindications

General MSK Screening

1. What treatment have you received so far for THIS problem?

2. Have you ever had other injuries, fractures or surgeries? If yes, list them including date.

3. Do you take any medications? Are you experiencing any difficulties with this medication? Which one(s)?

4. Do you have any allergies? Which one(s)?

5. Do you have any metallic implants? Where?

6. Have you ever been diagnosed as having any of the following conditions?(Circle YES or NO for each of them)

a. Rheumatoid Arthritis YES NO

b. Other Arthritis Condition YES NO

c. Osteoprosis YES NO

d. Haemophilia YES NO

e. Cardiovascular problem YES NO

f. Heart Attack YES NO

g. High Blood Pressure YES NO

h. Stroke YES NO

i. Cancer YES NO

j. Thyroid Disease YES NO

k. Diabetes YES NO

l. Tuberculosis YES NO

m. Epilepsy YES NO

n. Multiple Sclerosis YES NO

o. Respiratory Problem YES NO

p. Anemia YES NO

q. Kidney Disease YES NO

7. Do you have any unexplained weight loss? YES NO

8. If you are female, are you pregnant or trying to get pregnant? YES NO

9. Do you have any other known diagnoses or related conditions? If yes, please specify:

YES NO

10. Do you have other concerns that you would like to mention?If yes, please specify:

YES NO

Member Signature Date

Although the length of time a member has experienced symptoms serves as a biological marker or reference point, the severity and the nature of symptoms determine the clinical status and the priority level

Important to assign all patients the appropriate priority to ensure care is given to those most in need

Priority System

Symptoms have been present for less than 10 days, and if the patient is experiencing at least five of these six conditions:◦ Neurological symptoms◦ Severe pain (8-10 NRS)◦ Not able to work◦ Difficulty performing activities of daily living◦ Unable to participate in physical training◦ Altered sleeping patterns due to pain

In such a case, an appointment must be scheduled within two working days

A member who is to be deployed or is post-casting or post-surgery, must be considered a priority one

Acute (Priority 1)

Symptoms have been present for 10 days to seven weeks, and the patient is experiencing at least four of these five conditions:◦ Neurological symptoms◦ Moderate pain (5-7 NRS)◦ Able to work with restrictions◦ Able to perform activities of daily living◦ Able to participate in limited physical training

In such a case, an appointment must be scheduled within ten days

Sub-acute (Priority 2)

Symptoms have been present for more than seven weeks, and if the patient is experiencing at least three of these four conditions:◦ No neurological symptoms◦ Minor pain (0-4 NRS)◦ Able to work without restrictions◦ Able to participate in unrestricted physical

training In such a case, an appointment must be

scheduled within four weeks

Chronic (Priority 3)

When symptoms are of sufficient severity that the patient may need to be seen immediately by the physiotherapist

For this to occur, the referring practitioner should contact the physiotherapy department directly to discuss the case with the senior physical therapist technician

Medical Emergency

When a member requires physiotherapy services prior to operational deployment

The appropriate clinical priority (1, 2 or 3) must be given, but due to operational considerations, increased scheduling priority may be given

Operational Priority

Scheduling is essential to maintain client flow and departmental organization

Patient appointments need to be recorded either electronically or on a calendar/log book

The schedule should be organized by day, time and for each PTT

More time is required for an initial assessment than a follow-up appointments:◦ Initial assessments (I/A) = 60 mins◦ Follow-ups(F/U) = 30 mins

PT Scheduling

Friday, 30 Aug 2013

PT Tech 1 PT Tech 2 PT Tech 3 PT Tech 4

0800-0830 I/A:Mr. A

F/U: Mr. F F/U: Mrs. C I/A: Mr. B

0830-0900 F/U: Mr. G I/A: Mrs. D

0900-0930 BREAK I/A: Mrs. B F/U: Mr. H

0930-1000 I/A: Mr. C BREAK F/U: Mr. K

1000-1030 BREAK I/A: Mr. L BREAK

1030-1100 F/U: Mr. D I/A: Mr. I F/U: Mr. O

1100-1130 F/U: Mr. E F/U: Mr. M I/A: Mrs. E

1130-1200 F/U: Mrs. A F/U: Mr. J F/U: Mr. N

1200-1230 LUNCH LUNCH LUNCH LUNCH

Example Schedule

Once the patient has been given an initial assessment appointment, they will be seen for an evaluation by the senior PTT

A detailed initial assessment will be conducted to evaluate the patient’s current status and determine the treatment plan

After, the senior PTT will complete a treatment plan form and will pass the patient on to a junior PTT to carry out the treatment

Initial Assessments

Treatment Plan Form

CHARTING

Charting is the task of creating a patient’s medical record

Contains information regarding the patient’s previous and current medical conditions and treatment

Begins when the patient arrives at the healthcare facility, at which time the patient’s name, address and other information is registered into the admission book and chart

Charting

Records must be legible, accurate, and appropriate

Must be permanent ink and include original signatures, printed names and date◦ A log of all PTTs signatures and initials should be

maintained for cross reference purposes

All errors must be crossed out with a single line◦ They should be initialized by the PTT that made the

error and amendment

General Charting Guidelines

A problem-oriented charting system Begins with the patient’s medical history

and assessment A problem list is created based on the

patient’s assessment by the senior PT tech, and a care plan is developed that details how the PTT is going to address each problem

Progress notes are written after each treatment session and at discharge

“SOAPIE” Charting

Information is entered into the chart using SOAPIE format:◦ Subjective findings◦ Objective findings◦ Assessment data◦ Plan◦ Intervention◦ Evaluation

SOAPIE

This is information that the patient tells you about their condition

The patient’s chief complaint◦ Why they are getting PT?

Often refers to where, when and how much pain the patient is suffering

Examples:◦ S:"I have a 10 out of 10 pain level “◦ S: “I get pain in my left knee when I go up the

stairs”

S-Subjective Data

The symptom or group of symptoms which cause the patient to seek medical attention

The chief complaint drives the exam

This information is recorded as part of the subjective exam (Under the “S”)

Usually written in the patient's own words or in the words of a caregiver

Chief Complaint

This is the information that is based on clinical examination or testing

Quantifiable or measurable data Includes information such as:

◦ ROM◦ Strength testing◦ Swelling or girth measurements◦ Functional movements◦ Outcome measures/tests

O- Objective Data

Includes your conclusion based on subjective and objective data:◦ Is the patient better, worse or no different?

It will include the medical diagnosis given to the patient by the doctor

Can also include a differential diagnosis (DDX) if appropriate:◦ A list of other possible diagnoses usually in order of

most to least likely Examples:

◦ A: Patient is a 37 year old man on post-operative day 2 for a below knee amputation

◦ A: Back pain improving. DDX- Disc herniation

A- Assessment Data

The strategy for addressing the patient’s problem

Determined by the doctor or the senior PT tech and then passed on to a junior PT tech

Treatment should be specific and include all parameters

Examples:◦ P: Managed with ultra sound (1mHz, Continuous,

0.8w/cm², 5 mins)◦ P: Managed neck pain with ROM exercises (c/s

flexion, extension, rotation and side flexion-10/3x/day)

P- Plan

Includes the measures taken to care for the patient (the actual treatment provided)

Each treatment needs to be recorded Any changes to the treatment plan also

need to be indicated Examples:

◦ I: TENS (as per tx plan) x15 mins◦ I: AROM to wrist and elbow (flex, extension,

pronation and supination)- 10 reps/2 sets

I- Intervention

Includes the patient’s response to the treatment as well as the effectiveness

Can include the patient’s subjective response as well as an objective measure

Re-test the concordant sign and report results

Examples:◦ E: Patient reported reduced pain of 3/10 pain with

squat◦ E: Tolerated treatment well. No report of pain.

E- Evaluation

Testing used to objectively determine the change in function of a patient during the course of treatment

During the initial assessment baseline function is measured using a validated instrument

Once treatment has commenced, the same instrument can be used to determine progress and efficacy of treatment

Important for tracking patient progress as well as quality of care

Outcome Measures

Outcome measures require three criteria:◦ Should test the particular aspect of function that

it is intended to test = VALIDITY

◦ The results should be the same (or similar) regardless of who administers the test or when it is administered = RELIBILITY

◦ The test or scale should be able to detect change in function over time = RESPONSIVINESS

Continued . . .

There are numerous tests that can be used to determine outcome measures, however the following are best used by the ANA PTT:◦ Upper Extremity Functional Scale (UEFS)◦ Lower Extremity Functional Scale (LEFS)◦ Neck Disability Index (NDI)◦ Roland-Morris Disability Questionnaire ◦ Numeric Rating Scale for Pain (NRS)◦ Oxford Scale for Strength

PT Outcome Measures

Self-administered questionnaire which can be used to measure the impact of upper extremity disorders

Reports on 20 daily activities involving the upper extremity

Patients answer the question "Today, do you or would you have any difficulty at all with:" in regards to eight different activities

Max Score = 80 (High functioning) Min Score = 0 (Low functioning)

Upper Extremity Functional Scale

Intended for use on adults with lower extremity conditions

A self-administered questionnaire Patients answer the question "Today, do you

or would you have any difficulty at all with:" in regards to twenty different activities

Max Score = 80 (High functioning) Min Score = 0 (Low functioning)

Lower Extremity Functional Scale

A patient-completed, condition-specific functional status questionnaire with 10 items

Intended population:◦ Chronic neck pain ◦ musculoskeletal neck pain ◦ whiplash injuries◦ Cervical radiculopathy

Each section is scored on a 0 to 5 rating scale◦ 0 = 'No pain' ◦ 5 = 'Worst imaginable pain'

The points summed to a total score◦ Maximum score of 50

Neck Disability Index

Designed to assess self-rated physical disability caused by low back pain

Patient selects a statement when it applies to them that specific day◦ This makes it possible to follow changes over time

Score is the sum of the selected boxes Score ranges:

◦ 0 (no disability) to 24 (max disability)

Roland-Morris Questionnaire

DISABILITY RATING SCALE FOR LOW BACK PAIN

When your back hurts, you may find it difficult to do some of the things you normally do.

This list contains some sentences that people have used to describe themselves when they have back pain. When you read them, you may find that some get your attention because they describe your situation today. As you read the list, think of yourself today. When you read a sentence that describes you today, put a checkmark in the box next to it. If the sentence does not describe you, then leave the box blank and go on to the next one. Remember, checkmark the sentence only if you are sure that it describes you today.

1. I stay at home most of the day because of my back pain.2. I change my position frequently to allow my back to be more comfortable3. I walk slower than usual because of my back pain.4. Because of my back pain, I am not doing any of the jobs that I usually do around the house.5. Because of my back pain, I use a handrail to get upstairs.6. Because of my back pain, I lie down to rest more often than usual.7. Because of my back pain, I have to hold on to something to get out of an armchair.8. Because of my back pain, I ask other people to do things for me.9. I get dressed slower than usual because of my back pain.10. I stand up only for short periods of time because of my back pain.11. Because of my back pain, I try not to bend over or kneel down.12. I find it difficult to get out of a straight-backed chair because of my back pain.13. My back is painful most of the day.14. I find it difficult to turn over in bed because of my back pain.15. Because of my back pain, my appetite is not very good.16. I have trouble putting on my socks (or stockings) because of my back pain.17. Because of my back pain, I walk only short distances.18. I sleep less than usual because of my back pain.19. Because of my back pain, I get dressed with help from someone else.20. I spend most of the day sitting because of my back pain.21. I avoid heavy jobs around the house because of my back pain.22. Because of my back pain, I am more irritable and bad tempered than usual with people.23. Because of my back pain, I go upstairs slower than usual.24. I stay in bed most of the day because of my back pain.

A single 11-point self-reported numeric scale to rate pain

Has a variety of uses:◦ Pain at that moment◦ An average pain score◦ Over a specific time frame (i.e. the past week)◦ Doing a specific activity

0 represents one pain extreme (“no pain”) 10 represents the other pain extreme (“pain

as bad as you can imagine” or “worst pain imaginable”)

Numeric Rating Scale for Pain

Used to manually assess muscle strength Usually done as part of the objective

assessment Used to help develop an appropriate

strengthening/rehabilitation program Muscle strength is graded 0 to 5 Poor intra-rater reliability between testers

◦ Therefore important the same PTT perform repeat testing throughout the patients treatment

Oxford Scale

Oxford Scale

OUTSIDE REFERRALS

If patients require an orthoses or gait aid, it will be prescribed by a doctor

The PT tech will contact the ICRC representative who will then facilitate getting the required piece of equipment for the patient

The patient’s chart should include:◦ The type of equipment prescribed◦ The date of the request◦ The date the patient received the equipment◦ The instructions given to the patient◦ The response of the patient to the equipment

Orthoses Referrals

If patient’s are required to transfer to another floor, clinic or hospital, it is important to:◦ Ensure their chart is complete and up-to-date◦ Complete a discharge summary◦ Prepare any necessary transfer paperwork◦ Ensure the patient is provided with, and

understands their care plan

The actual transfer process will not be facilitated by the PT department

Clinic Transfers

DISCHARGES

Discharges are completed when:◦ The patient has recovered from their condition◦ The patient has reached the discharge criteria ◦ The patient stops attending PT◦ The doctor has discontinued PT◦ The patient wishes to stop PT◦ The patient is not responding to PT treatment

At discharge, it is important to evaluate and document the patient’s functional status as compared to their initial assessment

Discharges

A plan should be developed to assist the patient in ongoing maintenance and improvement of functioning after they are discharged from hospital or out-patient therapy

Discharge criteria should be established as early as possible in the treatment

The problem list can be used to establish discharge criteria

Should consider SMART goals

Discharges Continued . . .

Use SMART goals when establishing discharge criteria:◦S= Specific◦M= Measurable◦A= Attainable◦R= Relevant◦T= Time Specific

SMART Goal Setting

A 24 year old ANA male has suffered from a femur fracture of his left leg after a motor vehicle accident. His leg has been externally fixed. His initial problem list is as follows:◦ Average pain of 6/10 in right thigh◦ Non-ambulatory, in a wheel chair◦ 3/5 strength of right hip flexor, quads and gluts◦ 4/5 strength of right hamstrings and calf◦ Decreased light touch sensation to right anterior

thigh◦ Bed mobility and transfers requires one assist

Discharge Criteria Example

From the initial problem list, discharge criteria can be created as follows:

Within the next 6 weeks, the member will: ◦ Manage pain to 2/10 or less◦ Ambulate independently with crutches or a cane◦ Have 4/5 strength of quads, gluts and hip flexors◦ Have 4+/5 strength of hamstrings and calf◦ Regain normal sensation to anterior thigh◦ Have independent bed mobility and transfers◦ Have a home support network in place for his return

home

Continued . . .

Discharge criteria can change at any point throughout treatment

Goals may change due to:◦ Speed of recovery◦ Complications◦ Support networks◦ Patient’s goals and motivation◦ Transfer to another clinic or hospital

Ensure discharge criteria are reviewed regularly and any necessary adjustments made

Continued . . .

Treatment cannot be provided without attaining informed consent from a patient first

PT referrals need to be prioritized based on the presenting signs and symptoms of the patient

Charting is mandatory for all patients and all visits. The acronym SOAPIE is used to help guide charting standards

Outcome measures should be used at the first and last visit to quantify the status and changes in the patient and the effectiveness of the treatment

Summary

Outcome measures are specific to an area of the body or condition

Discharge criteria needs to be established as soon as possible in patient treatment

PT problem lists will help generate discharge planning criteria

Discharge criteria is flexible and may change repeatedly

Summary Continued . . .

Questions?

1. What is informed consent?

2. How soon should a patient who is prioritized as Priority 1 been seen by PT?

3. What are the criteria for a priority 3?

4. What does the acronym SOAPIE stand for?

Comprehension Check

5. What are the 3 criteria that outcome measures have to have?

6. What would be an appropriate outcome measure for a leg amputee patient?

7. How criteria should discharge goals meet?

Comprehension Check

1. Informed consent is consent by a patient to undergo or participate in a medical treatment after the patient understands the risks involved

2. Priority 1 patients need to be seen within 2 working days

3. The criteria for a priority 3 patient is at least three of these four conditions:

◦ No neurological symptoms◦ Minor pain (0-4 NRS)◦ Able to work without restrictions◦ Able to participate in unrestricted physical training

Answers

4. SOAPIE stands for:◦ S= Subjective data◦ O= Objective data◦ A= Assessment data◦ P= Plan◦ I= Intervention◦ E= Evaluation

5. The 3 criteria for outcome measures are:◦ Validity◦ Reliability◦ Responsiveness

Answers

6. Patients with lower limb injuries should use the Lower Extremity Functional Scale outcome measure

7. Discharge goals should be “SMART”◦ S= Specific◦ M= Measurable◦ A= Attainable◦ R= Relevant◦ T=Time specific

Answers