Documenting the Assessment: Summary and Diagnosis,



Documenting the Assessment


Summary and Diagnosis



LEARNING OBJECTIVES


After reading this chapter and completing the exercises, the reader will be able to:


1. Describe the role of physical therapists in establishing and documenting a diagnosis.


2. Describe the characteristics of the Assessment section of an evaluation report.


3. Appropriately document an Assessment for different case scenarios.


This chapter presents the Assessment section of the initial evaluation documentation by the PT. The assessment is a pivotal section of the initial evaluation. In it, the PT draws on information presented in the previous sections to arrive at a decision regarding the main problems to be addressed and the probable causes of those problems. The sections of the initial evaluation that follow the Assessment are used to propose goals and a plan for achieving those goals.


The Assessment section has three purposes: (1) to provide a summary of the evaluation and the PT’s clinical judgments about the case; (2) to confirm, extend or, if necessary, question the referral diagnosis; and (3) to justify the necessity of physical therapy intervention.


The notion that PTs make a diagnosis is an important one and has become more readily accepted within the physical therapy and medical communities. Therefore this chapter begins with an explanation of diagnosis and a consideration of the rationale for diagnosis by PTs. The case examples at the end of this chapter provide sample documentation of the Assessment section in various clinical settings.



Diagnosis by Physical Therapists


DEFINITION OF DIAGNOSIS


The term diagnosis refers to both a process and the product of that process. In a general sense, diagnosis as a process is an investigation or analysis of the cause or nature of a condition, situation, or problem. Diagnosis as a product is a statement or conclusion from such an analysis, typically a recognizable label that identifies the nature or the cause of the problem. Thus an auto mechanic can diagnose what is wrong with a car, or an electronics technician can arrive at a diagnosis as to what is wrong with a computer. In medicine, diagnosis has traditionally referred to the act of identifying a disease from its signs and symptoms as well to the decision reached by that process. In medicine the diagnostic label often identifies the pathology or disease process presumed to be the underlying cause of the patient’s signs and symptoms.


Diagnosis in physical therapy has been considered controversial because some believe that it should be the sole prerogative of physicians. Indeed, some would argue that PTs do not have the training to make a correct diagnosis of a patient’s condition, nor are they able to order and interpret the myriad of tests available to the modern physician. However, this perspective is based on a strict definition of diagnosis—that it is the act of determining the nature and location of a pathologic condition. If a broader view is used—that diagnosis is the process by which any professional, not just a physician, determines the cause of a problem—then the term can be used to describe the process that PTs use to determine the causes of the problems faced by their patients.



DIAGNOSTIC PROCESS


The term diagnosis refers to a process that all PTs engage in: the act of evaluating the physical and subjective findings to make a decision about whether physical therapy will be helpful to a patient and, if so, what kind of therapy the patient should receive. The diagnostic process involves making a clinical judgment based on information obtained from history, signs, symptoms, examination, and tests that the therapist performs or requests. Different methods of diagnosis have been advocated; a few are discussed briefly in Figure 9-1 (also see References).


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FIGURE 9-1 Different methods can be used in the process of formulating a diagnosis.

The American Physical Therapy Association’s House of Delegates has shifted its position from one that recognizes the right of a PT to make a diagnosis (“may establish” in 1984; APTA HOD, 1984) to one that requires a diagnosis for each patient (“shall establish” in 2007; APTAHOD, 2007) (Box 9-1). However, any diagnosis or classification should be within the legal realm of physical therapy, as defined by state practice acts (Jette, 1990).



BOX 9-1   Resolutions of the American Physical Therapy Association House of Delegates Relevant to Diagnosis


DIAGNOSIS BY PHYSICAL THERAPISTS HOD P06-08-06-07 (Program 32) [Amended HOD P06-97-06-19 HOD 06-95-12-07; HOD 06-94-22-35, Initial HOD 06-84-19-78] [Position]


Physical therapists shall establish a diagnosis for each patient/client. Prior to making a patient/client management decision, physical therapists shall utilize the diagnostic process in order to establish a diagnosis for the specific conditions in need of the physical therapist’s attention.


A diagnosis is a label encompassing a cluster of signs and symptoms commonly associated with a disorder or syndrome or category of impairment, functional limitation, or disability. It is the decision reached as a result of the diagnostic process, which is the evaluation of information obtained from the patient/client examination. The purpose of the diagnosis is to guide the physical therapist in determining the most appropriate intervention strategy for each patient/client. In the event the diagnostic process does not yield an identifiable cluster, disorder, syndrome, or category, intervention may be directed toward the alleviation of symptoms and remediation of impairment, functional limitation, or disability.


The diagnostic process includes obtaining relevant history, performing systems review, selecting and administering specific tests and measures, and may include the ordering of tests that are performed and interpreted by other health professionals. The physical therapist’s responsibility in the diagnostic process is to organize and interpret all relevant data.


In performing the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other health professionals. In addition, as the diagnostic process continues, physical therapists may identify findings that should be shared with other health professionals, including referral sources, to ensure optimal patient/client care. When the patient/client is referred with a previously established diagnosis, the physical therapist should determine that the clinical findings are consistent with that diagnosis. If the diagnostic process reveals findings that are outside the scope of the physical therapist’s knowledge, experience, or expertise, the physical therapist should then refer the patient/client to an appropriate practitioner.


Thus the PT has a professional responsibility to engage in the diagnostic process even when the patient has been referred with a diagnosis by a physician. First and foremost, the PT must determine whether the patient’s condition is appropriate for physical therapy intervention. Going through the process of determining that a patient’s condition is appropriate for physical therapy by ruling out medical conditions that would be inappropriate requires, in effect, that the therapist make a diagnostic decision regarding the nature of the pathology and its severity. Deciding that the pathology causing a patient’s pain is not cancer, not myocardial infarction, and not an infection in the kidney requires a diagnostic process in which the nature of the pathology is investigated. (Some use the term screening to refer to this process.) Thus in all cases the PT is making a diagnostic decision, even though he or she is not actually making the final determination of the diagnostic label.


In addition, in the course of assessing the patient or in review when a patient does not respond to treatment, information is often uncovered that may necessitate modification or rethinking of the original diagnosis. In this case, it is the legal and professional responsibility of the PT to bring this information to the attention of the referring practitioner. This does not mean that the PT is responsible for making the definitive determination of the diagnosis. This will, for the most part, remain the responsibility of the physician, even in direct-access environments. In modern health care environments, where the PT is often one of several specialists seeing a patient, he or she participates in the process and helps the physician reach the correct diagnosis.



DIAGNOSTIC LABELS


Although there is widespread agreement among PTs about the importance of the diagnostic process, real questions exist regarding the form of the result (the diagnostic label). Some have argued that the PT should establish a physical therapy diagnosis separate from the medical diagnosis; we adopted that framework in the first edition of this text. We now believe that such an approach creates confusion. The diagnostic label should be used by PTs as it is ordinarily understood by other health care professionals, that is, as identifying the underlying disease or pathologic process presumed to be responsible for the patient’s condition. This is the common understanding of the term used by all health professionals. There are certainly instances in which not enough is known about a condition to specify its cause so precisely. In these cases the diagnostic label will necessarily be descriptive (e.g., a syndrome). Because the diagnostic label often lacks pathologic specificity, Sackett and Haynes (2002) proposed considering the label as identifying the “target disorder,” which he defined as “the anatomical, biochemical, physiologic, or psychologic derangement.” We refer to this target disorder, the diagnostic label usually determined by the referring physician but often confirmed or extended by the PT, as the differential diagnosis.


Besides the overriding concern about preventing confusion, there are also significant positive reasons for using a common diagnostic label. Perhaps most importantly, physicians and other referring professionals need to learn which diagnoses are appropriate for referral to a PT. Physicians will not learn this if PTs use an alternate and essentially exclusive system. By the same token, the reimbursement systems as well as most large outcome databases are inextricably linked to diagnoses (i.e., ICD-9 or ICD-10 codes). Finally, the database of clinical research evidence that PTs both use and contribute to is primarily organized around the pathology-based diagnostic system.


Although in many cases the diagnoses of the physician and PT remain distinct, at times these diagnostic processes overlap. For example, PTs typically perform a general screening (referred to as a systems review in the Guide to Physical Therapist Practice,2001) to rule out serious pathologic conditions, such as tumors or heart disease, that are not appropriate for physical therapy intervention. This is sometimes referred to within the physical therapy community as differential diagnosis. If evidence of such a pathologic condition is found, the PT must refer the patient to an appropriate practitioner for further testing. This requires the therapist to at least consider the possible pathologic conditions, even if he or she will not verify their presence or absence. Thus specific tests and measures used in the differential diagnosis process must be documented in the evaluation, and any modifications to the medical diagnosis based on a physical therapist’s findings that are within his or her legal purview to make, should be documented in the Assessment.



PHYSICAL THERAPY DIAGNOSTIC SYSTEMS


The notion of a physical therapy diagnosis, referred to earlier, arose from the belief by many PTs that the traditional medical diagnosis was not particularly helpful in directing intervention. In this view, the process of diagnosis should involve classifying or labeling the dysfunction—typically at the impairment level or, in ICF terms, at the level of body structure and function. Physical therapy, however, does not yet have generally agreed upon labels or classification systems, although much current research activity is aimed at creating and testing diagnostic systems (Scheets et al., 1999; Delitto and Snyder-Mackler, 1995). At present, two or three different types of systems are used that provide standardized labels or classifications of diagnosis for patients seen by PTs:



1. Guide to Physical Therapist Practice, part II: preferred practice patterns (Figure 9-2). The preferred practice patterns defined in the Guide are accepted as diagnoses made by physical therapists. These practice patterns encompass many possible ICD-9 diagnoses. They classify patients according to a clustering of impairments and related health conditions.


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FIGURE 9-2 Preferred practice patterns from the Guide to Physical Therapist Practice (2001).


Since their introduction, the preferred practice patterns have not gained widespread acceptance in clinical settings, which may be because these patterns lack specificity. Within each practice pattern, the tests and measures and interventions that can be used are virtually identical. Thus categorizing patients into a pattern does little to assist the therapist in treatment planning and clinical decision making.


2. Classification systems. PTs have become the practitioners who have the appropriate training to develop a proper diagnosis of the causes of movement dysfunction. Much research is currently underway to develop diagnostic classification schemes, or treatment-based classifications, for certain patient populations, including stroke (Scheets et al., 2007), low back dysfunction (Delitto et al., 1995; George & Delitto, 2005; Van Dillen et al., 1998), and neck pain (Fritz & Brennan, 2007). The primary purpose of such classification systems is that subgroups of patients can be identified from key history and examination findings, and these subgroups can then be given distinctively different interventions that are specially suited to their condition. The classification of subgroups is based not on health condition, but typically on a combination of findings at the level of impairments and activities.


    A very important role of classification in diagnosis is the determination of etiology (literally, what caused the disorder). In many instances, especially when there is a musculoskeletal disorder, the PT must determine whether the patient’s abnormal movement or postural patterns caused the disorder or are the result of the disorder. Many current classification systems emphasize this distinction. Other classification schemes are based on what types of treatment approach the disorder is most likely to respond to.


    Use of classification systems is still relatively new in regard to research efficacy, but it can have a potentially powerful impact on clinical decision making in physical therapy. With this in mind, we encourage therapists to incorporate this research into clinical practice where appropriate; this is also an area in which continued research is warranted.


3. Disablement systems. Guccione (1991) advocated for diagnosis by PTs to be focused on the relation between impairments and functional limitations, based on the Nagi model. Indeed, we advocated for a similar definition in the first edition of this textbook. With the adoption of the ICF framework and terminology, a more global classification system for considering diagnosis is warranted. We argue that diagnoses within the ICF framework should not just link two of the levels (impairments and activities), but rather include links within all levels of the framework (health condition, body structures and functions, activities and participation, as well as personal and societal factors). Indeed, it has been recently recommended that enablement models should inform but not constrain any diagnostic descriptors that are developed (Norton, 2007).

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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Documenting the Assessment: Summary and Diagnosis,

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