Clinical Decision Making

Clinical Decision Making

Russ Tolliver

Office- 904-520-8729

Clinical Decision-Making

The process by which we utilize evaluative data, the patient’s individual needs and clinical judgment to formulate the most appropriate treatment strategies to achieve the desired outcomes.

Evaluation

Gathering subjective data from the patient/family/facility staff.– Perceived patient/problems/goals for treatment.

• What does the patient/family/facility staff perceive as the problem or functional limitation?

• What would the patient/family/facility staff want to accomplish from the patient participating in therapy?

• If injury or fall, what are the circumstances surrounding the injury?

Evaluation- Subjective Data

Prior level of function– What was the patient’s level of function prior

to the injury or exacerbation of the condition?If the patient is unable to provide, ask the facility staff or family/responsible party.

Evaluation- Subjective Data

Anticipated Discharge Plan– What is the discharge plan for the patient?– If returning to a less structured environment,

will the patient be expected to be independent or will assistance be available?

Evaluation- Subjective Date

Feedback from the facility staff– If the patient is unable to provide subjective

data, what feedback can the facility offer relating to the patients PLOF, current functional limitations or other relevant information.

Evaluation-Objective Data

Gathering objective data– Past medical history

• What are the past medical conditions or co-morbidities that exist that may influence the course of treatment?

• I.E. (the patient has a colostomy bag; resident is visually impaired and has deficits and impairments with mobility.

Evaluation- Objective Data

Prior therapeutic interventions and results– Were the results of prior therapy favorable?– Did barriers exist that impacted treatment?– If the patient received treatment for the same

condition, what elements have changed that require skilled intervention with PT/OT/SLP services now?

Evaluation- Objective Date

Tests-Measurements– Does the objective data match the clinical

presentation?• Which tests-measurements should be collected

based on the subjective data and/or observations?

What standardized testing can be utilized?– Tinetti, Berg for balance– Purdue peg board for fine motor dexterity– Western Aphasia for comprehension/speech

Evaluation- Clinical Judgment

Process by which the clinician utilizes information gathered during the evaluation to determine the best course of action.– Clinical Findings– Extent of loss of function– Social consideration

• Home environment• Family involvement• Participation in activities• Financial


Establishing goals– What will be the optimal level of improvement

for the patient based on:• Reason for referral?

• Personal goals for therapy, motivational level?

• Response, participation level in prior therapy?

• Prior level of function? Severity of functional limitations?

• Discharge Plan


Establishing goals (continued)– What are the expected outcomes?– How can these be documented in objective,

measurable, and functional terms?


Creating a treatment plan– What procedures, modalities should be used

that are consistent with treating the patient’s diagnosis and symptomology?

• TE,TA,ADL,NM-Re-Ed, W/C mobility, SELF CARE dysfunctions.

• Treatment of swallowing dysfunction and/or oral function, speech/language, voice, communication and auditory processing.

Evaluation-Clinical Judgment

Determining the Frequency and Duration– What is the appropriate time frame that will be

required based in the individual’s needs?– Does the condition require intensive

treatment?– Is the patient’s health status stable to tolerate

the recommended intensity?– Should the intensity be reduced as the patient

gains independence?

Clinical Decision- MakingA comprehensive, well written evaluation serves as a cornerstone for future clinical reasoning and decision-making.

S U B JE C T IV EO B JE C T IV E

D A T A

G O A LS T R E A T M E N T P L A N S D IS C H A R G E P L A N S

C L IN IC A L R E A S O N IN G


Treatment Progression– How do we know when to progress the patient

within their established treatment plans?• I.E. (Next goal or skilled activity)

Patient’s response to treatment– Musculoskeletal System– Cardio-vascular System– Respiratory System– Gastro-Intestinal System


Treatment Progression( Continued)– Patient’s ability to perform activities utilizing

safe techniques in mobility, feeding, swallowing, etc.

– Patient’s ability to demonstrate functional application of skilled activities.

– Patient’s ability to increase the consistency of performing functional activity tasks.

Assessments

As the patient makes progress towards goals, assessments should occur frequently and be an on-going process to ensure the treatment strategies are appropriate for the patients plan of care.

Re-Evaluation/Re-CertificationAt least every 30 days, a formal

Re-Evaluation/Re-Certification should occur for every patient regardless of payor source.

Support the medical necessity for continuanceAdvance/Adjust the patients goalsDescribe the treatment plan (proc,mod/freq/dur)Can occur with new clinical findings or failure to

respond to therapy interventions(less than 30 days).

Clinical Decision-Making (Minimal progress)

What questions can we ask ourselves if the patient is making minimal to no progress towards goals?

– Time of day of treatment appropriate

– Medication Issues

– Goals to aggressive

– Patient instructions to complex

– Treatment techniques to aggressive for patients condition

– Goals to “aggressive” or to “advanced”

Clinical Decision-MakingMinimal Progress

What changes can be made to the treatment approach to improve the patients progress?

– Alter the time of treatment in the day

– Increase rest breaks

– Split treatments

– Reduce frequency


Changes to treatment approach• Provide different treatment strategies to

accommodate the patient’s needs

• Revise goals

• Have different therapist in the same discipline treat the patient

• Conduct peer review or team conference to discuss


RefusalsIf the patient refuses over several days, the

therapy program should be put on hold until the patient is willing to attempt performance of the functional activity and investigation with the nursing staff should occur to determine the cause of refusal.

Discharge

How do we know when to discharge our patients?• Achieved maximum benefit from skilled intervention.

• Progress towards goals has plateaued– Determining factors for plateau

• Changes in medical conditions

• Physical limitation

• Request for self-discharge

• Physician discharge orders based on physician exam

• Discharge to another facility

• Patient expiration

QUESTIONS?

Documents

Clinical Decision Making