CLINICAL DECISION

MAKING
 Regardless of which component of
patient/client management PTs address at
any point in time and which model they use
in the process, they are making decisions at
many levels.

 May’s model is useful for considering

decisions in every component of
patient/client management

 For instance, a pediatric PT may make the

following kinds of decisions:
 Standard familiar decisions: The PT’s knowledge
and experience make these decisions almost
automatic. For example, 85% of a PT’s caseload
may be made up of children with developmental
delays. Patient/client management
 Standard unfamiliar decisions: The diagnosis and

treatments for a condition are well known or at

least supported by research but are not
commonly encountered. For example, the same
PT as above may be assigned toriticoliss
 Open familiar decisions: These are familiar
decisions that involve some idiosyncratic element,
such that further investigation or new strategies
are required. For example, the pediatric PT may be
assigned a new patient with developmental delays
who also has visual and hearing impairments;

 Open unfamiliar decisions: These decisions involve

confusing or conflicting information that requires
longer and more careful consideration. For
example, the parents of a child with
developmental delays may request that the PT
incorporate US into the treatment sessions;
otherwise they will take the child to another PT.
REFERRAL RELATIONSHIPS
 PTs in the military, sports and public health
services routinely have practiced without referrals.

 Before 1960s, the general public typically had

access to physical therapy services only through
prescriptions written by physicians

 now More than 30 states have passed legislation

allowing the public direct access to PTs and in 48
states PTs can perform initial examinations without
a physician’s referral
 However, the form of the required referral has
changed. Most physicians now refer a patient for
physical therapy without prescribing a detailed
program; the referral simply reads, “Evaluate and
treat,,

 this change altered patient/client management by

PT s, who have moved from the more technical role
of implementing plans of care as instructed by
prescription to total responsibility for the
patient/client management process, from
examination to outcomes

 This increased the responsibility to refer a patient to

a physician when the PT identifies problems beyond
the scope of physical therapy.
 A shift may be seen in the physical therapy
profession toward marketing directly to
patients and also to physicians, who will
continue to make referrals. Both physicians
and patients will have more choices in
directly selecting a PT.

 Establishing professional trust with the public

may become more important than referrals
in attracting potential patients directly and in
seeking contracts with third-party payer.

 Reimbursement without a physician’s referral

has the potential to reduce health care costs
because it requires fewer visits to the
physician and less paperwork.
 However, opponents of direct access suggest that it
may increase costs unless PTs are very good at
determining the physical therapy diagnosis and,
perhaps more important, the differential diagnoses

 Self-referral also has the potential to limit

opportunities for patients to seek the provider of
their choice if they believe their only choice is the
provider to whom the physician refers them.

 Physician employment of PTs has been on the

decline over the years and the number of PTs who
are better and more interested in private practice
has increased
INTERPERSONAL RELATIONSHIPS
 In the 1977 Mary McMillan , Mary Clyde reminded
the physical therapy profession of the importance
of its human side, seen in PTs’ devotion to human
welfare and in the need for PTs to be
compassionate, loving, understanding, and
conversant with the humanistic attribute of self
and the relationship with others

 but the challenges to the therapeutic relationship

in which it must be achieved have Some of these
challenges……..
 The need to address a broader range of cultural
issues

 Compliance with an ever-increasing number of

laws, regulations, and ethical

 principles that guide physical therapy practice

 Third-party interpretation of regulations governing

payment for services

 Increased access to information for both the PT and

the patient
 Increased accountability and responsibility
for care provided

 Employer productivity and caseload

expectations

 Professional development of the PT

 Quality of evidence supporting PTs’ decision

 ETHICAL AND LEGAL ISSUES
 Legal issues in patient/client management are
addressed in
1.state statutes,
2. practice acts

 which regulate the physical therapy profession. PTs

must be knowledgeable about the practice act in
each state in which they intend to work,

 Professional ethics, however, are guided by

professional documents common to all PTS

 A physical therapist shall place the patient’s/client’s

interests above those of the physical therapist
CODE OF ETHICS AND GUIDE FOR
PROFESSIONAL CONDUCT
 The APTA’s Guide for Professional Conduct20
(GPC) includes

 confidentiality

 trustworthiness or fidelity,

 respect for the individual’s rights and dignity

 autonomy of the patient

FACTORS IMPORTANT TO SUCCESSFUL
PHYSICAL THERAPY TREATMENT
1. The physical therapist’s treatment method is the
most decisive factor in the patient’s recovery.
2. A physical therapist should not become too
involved with the patient’s personal or social
problems;
3. Patient motivation is a vital component of
successful therapy.
5. Physical therapy should promote the patient’s
health rather than emphasizing the diagnosis.
6. The physical therapist’s knowledge and
technique are what make physical therapy work.
7. The physical therapist should not simply treat a
part of the body part, but rather should be
interested in the whole person.
8. Physical therapy should be oriented toward the patient’s
resources rather than the person’s problems.
9. The patient’s own capacity for recovery is a major factor
in the success of physical therapy.
10. Physical therapy is above all an aid to self-help; it
works by eliciting the patient’s own ability to change and
improve.
11. The interaction between the physical therapist and
patient that makes physical therapy successful begins
during the first therapy session.
12. The physical therapist should place less emphasis on
the patient’s diagnosis and more emphasis on enhancing
the individual’s coping skills.
13. The interaction that occurs between the client and
physical therapist has no bearing on asuccessful
treatment outcome.
14. The patient’s diagnosis should be the central focus of
attention in physical therapy.
INFORMED CONSENT
 informed consent as having five elements
 competence

 Disclosure

 understanding

 voluntariness

 consent.
 Although most PTs would agree that the PT has
an obligation to obtain informed consent from
the patient, some debate exists as to how this
should occur and how the process should be
described.

 this debate stems from the differences between

the PT’s role and that of the physician

 Which consent form should be applied if it is

necessary medical or surgical procedure.

 Ethical or legal because Some view informed

consent as primarily a legal rather than an
ethical concept
 what are the condition in which the consent form
must be used (Scott suggested that informed
consent should always be obtained before spinal
manipulation)

 A review of APTA documents points up the

uncertainty of the profession regarding appropriate
procedures for obtaining informed consent

 the physical therapy profession is still in the

process of reaching agreement on procedures for
doing so.
Thanks