Clinical Decision Making

Lecture outline
Clinical decision making process

APTA model

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





Models of Disablement

Disease sign symptoms
Impairments direct & indirect

Functional limitation

Disability


APTA Model of Practice
1. Examination
History
Systemic Review
Tests and Measurements
2. Evaluation
3. Diagnosis
4. Prognosis
5. Intervention
6. Reexamine
1
5
6
2
3 4
Components of Clinical Decision Making
1
5
6
2
3 4
Components of Clinical Decision Making
Examination
5
6
2
3 4
Components of Clinical Decision Making



History
Interview/Review of records
Family/Patient expectations and
desired outcomes

Past health status

Current health status

Social history

Key Questions

Family/Patient
goals

Patient
occupation

Family activities
and hobbies
Previous Therapies
Patients Progress
Medications, surgeries
Family Attitudes
and Knowledge of
Diagnosis

Available Family
Support Systems
Systems Review
Identification of issues
requiring referrals or
consultations
Status of:
Cardiopulmonary
Integumentary
Musculoskeletal
Neuromuscular
TESTS AND MEASURES

Content and Development
Validity
Reliability
Sensitivity
Specificity
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?

Psychometric Properties
What is Validity ?
The degree to which a measure represents what it intends to measure.
Psychometric Properties
Sensitivity
How well a test identifies people who truly have the
condition measured by the test.
Specificity
How well the test identifies people who do NOT
have the condition being measured.
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
Examination
5
6
Evaluation
3 4
Components of Clinical Decision Making
Evaluation

Examination
5
6
Evaluation
PT Diagnosis
4
Examination
5
6
Evaluation
PT Diagnosis
Prognosis
Plan of Care
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



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

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
Patient Centered Goals

Determine patients desired outcome of therapy
Require understanding of activities and
environments
Work
School
Self care
Leisure

Established with the patient to relate to desired
outcome

Five Elements of Patient Centered
Goals

By when?
How well?
Under what
conditions?
Will Do
What?
Who?
Patient Centered
Functional Goal
WHO
Is always the patient
in patient-centered
goals

WHAT

The activity the patient will perform
Related to the desired outcomes of therapy
Observable behavior
Repeatable
Definite beginning and ending
Avoid will be able toPt. WILL ambulate


UNDER WHAT CONDITIONS
Incorporates specific elements of a measure

May be distance, time, environmental variables

Must be a relevant measure
HOW WELL

Defines level of assistance needed

Defines number of successful attempts required

Requires specificity for reliability

Provides the set criterion for achievement
WHEN

Target date for
achievement of goal

Evidenced based
decision

Dates may change as
therapy progresses
Sample Goal


WHO
Sara will
WHAT
ambulate 100 feet
CONDITIONS
with Axillary crutches, NWBing on left, without loss of balance
HOW WELL
twice in two consecutive treatment sessions
WHEN
by March 8 2014.
Examination
Implementation
POC
6
Evaluation
PT Diagnosis
Prognosis and
plan of Care
Therapeutic Exercise
Functional Training
Adaptive Equipment
Wound Care
Gait Training
Patient Education
Examination
Implementation
POC
Outcomes
Re-examination
Evaluation
PT Diagnosis Plan of Care
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?
Examination
Implementation
Outcomes
Re-examination
Evaluation
PT Diagnosis Plan of Care
Evidenced Based Practice
Evidenced Based Practice
Research Clinical Expertise
Patient Preference
Examination
Implementation
Plan of Care
Outcome Measures
Re-examination
Evaluation
PT Diagnosis
Plan of Care
Prognosis
Patient
Preference
Research
Clinical
Expertise
Clinical Decision Making in Physical Therapy
Three components of Physical
Therapy Intervention
Coordination
Communication
Documentation

Patient / client related instruction

Procedural intervention

Intervention

Restorative
Compensatory
Preventative

FITT

EBP

Documentation

POMR (problem oriented medical record)
4 phases

Formation of database
Identification of problem
Identification of special treatment
Assessment of effective treatment

SOAP

Clinical decision making

Expert vs Novice

Knowledge base and experience

Cognitive processing style (receptive data gathering vs
procedural)

Self monitoring strategies

Communication and teaching skill


Thanks