Provison of Medical Administration

1. Provison of Medical Administration PO 001.02

2. Learning Objectives • 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

3. Continued . . . • 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

4. INFORMED CONSENT

5. 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

6. Elements of 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

7. WCPT and 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

8. Patient 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

9. Continued . . . • 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

10. What Happens if the Patient Does Not Give Informed Consent? • 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

11. PT REFERRALS

12. PT Referral Process • 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;

13. PT Referral Process Continued . . . • 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

14. PT Referral Form

15. Initial Assessment Process • 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

16. Referral Admission Book • 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

17. Admission Log Book

18. General MSK Screening • 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

20. Priority System • 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

21. Acute (Priority 1) • 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

22. Sub-acute (Priority 2) • 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

23. Chronic (Priority 3) • 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

24. Medical Emergency • 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

25. Operational Priority • 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

26. PT Scheduling • 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

27. Example Schedule

28. Initial Assessments • 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

29. Treatment Plan Form

30. CHARTING

31. 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

32. General Charting Guidelines • 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

33. “SOAPIE” Charting • 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

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

35. S-Subjective Data • 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”

36. Chief Complaint • 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

37. O- Objective Data • 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

38. A- Assessment 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

39. P- Plan • 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)

40. I- Intervention • 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

41. E- Evaluation • 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.

42. Outcome Measures • 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

43. Continued . . . • 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

44. PT Outcome Measures • 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

45. Upper Extremity Functional Scale • 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)

47. Lower 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)

49. Neck Disability Index • 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