Diagnosis Definition

Physical Therapy Diagnosis blog describes my evolution as a physical therapist clinic owner and how I developed a Medicare compliance program based on clinical excellence and simple measurements.

Other physical therapists have done work on physical therapy diagnosis , some of which I'm able to share with you here.

Diagnosis Definition
by Lisa Giallonardo

"A diagnosis is a label based on a cluster of signs and symptoms after the collection, organization, and interpretation of information reached through the evaluation process. For the physical therapist, these are generally movement-related impairments or functional limitations. Sometimes, as in the case of the patient with the ankle sprain, the diagnosis is at the pathology level."

Lisa's definition comes from the book Techniques in Musculoskeletal Rehabilitation by William Prentice and Michael Voight.


Most physical therapists (and physical therapist assistants) graduating today are comfortable with the notion of physical therapy diagnosis.

What about the 'old school' physical therapists? I graduated in 1992 from the University of Florida. I was never taught physical therapy diagnosis. I never learned about the disablement model in PT school.

What about you?

Where do you fall on this issue?

Vote in the poll below. Let us know how you feel. What do you think?

Comment on this blog if you feel strongly - either way, on physical therapy diagnosis.

Physical Therapy Technology

Physical Therapy Diagnosis blog uses technology such as blogs, YouTube videos, Google AdWords and AdSense and Web 2.0 in general to drive home the message that Physical Therapy Diagnosis is simple and easy.

Every Physical Therapist should perform Physical Therapy Diagnosis using skills learned in our entry-level program (BS, MS or DPT).

One physical therapist, Mark Schwall, uses technology in general to improve our lives and our businesses at his website at Tech4PT.com .

In Mark's words...

"TECH4PT.com is dedicated to informing and educating Physical Therapists and anybody else with an interest in utilization of technology to improve their personal lives, business productivity and the visibility of their practices through leveraging the power of availability of technology and the Internet ."

Technology is not usually found in physical therapy education curricula. Technology is also usually not in the skill set of the physical therapist - just look at the low acceptance of 'paperless' or electronic medical records in small outpatient physical therapist offices.

I congratulate Mark on his new website.

I also challenge Mark to find meaningful and useful ways to help physical therapists improve our patients lives through the power and the wonder of technology.

What is Skilled Physical Therapy?

What do you do?

What do you do better than anyone else?

What can you do better than an athletic trainer, a massage therapist or a kinesiotherapist?

Can you progress your patient to a new level of exercise intensity, frequency or duration? Can you back down the intensity, frequency or duration?

Can you assess some new finding or physical sign not in the initial plan of care?

Will the patient leave your care better off than when they arrived?

Was their outcome more certain?

Physical therapists are paid more than athletic trainers, massage therapists or kinesiotherapists precisely because we do bring a greater level of certainty to each patient encounter.

Physical therapists produce better outcomes because risky patients don’t get worse with exercise interventions.

Physical therapists are paid more than athletic trainers, massage therapists or kinesiotherapists because the physician can expect that patients would otherwise not be safe.

An example of a post-surgical total knee replacement will help to illustrate this point.

Even an athletic trainer is qualified to show the patient how to do leg lifts for a weak quadriceps muscle.

But what if the patient came to therapy with a swollen calf, red, tender skin and radiating pain into the groin? Would the athletic trainer recognize a blood clot? Would the massage therapist use a standardized scale like the Well’s score to quantify the risk, document the findings and call the doctor?

Quantify the risk using standardized scales so that terms like better, risky and more are not just superlative adverbs but can be used as measurements for goal setting.

An impairment goal of therapy would be to reduce a Well’s score from 2/9 to 0/9.

A Well’s score of ‘3’ is a high risk for a blood clot.

See also the Medicare Benefit Policy Manual Section 220.2.C (page 20) for a definition and examples of skilled therapy.

References: Journal of Family Practice Online, December 2007. Web Accessed 3/12/08

http://www.jfponline.com/Pages.asp?AID=5728&issue=December_2007&UID=

How to write a Medicare Progress Note

Watch this video to see an example of a Medicare Progress Note that fufills the minimum requirements as set forth in Transmittal 63 (Medicare Benefits Policy Manual).

In the video, I talk about medical necessity for physical therapy, justification statements in the plan of care and in subsequent progress notes, the re-certification note and more.

Finally, I tie it all together with the Physical Therapy Diagnosis.

What is a SOAP note?

There is lots of confusion and controversy, mainly confusion, about what constitutes a SOAP note.
Let’s first look at what insurers require in physical therapists’ documentation:

1. Evidence of Medical Necessity for Physical Therapy
2. Evidence of Skilled Physical Therapy services – that is, the services could not have been provided by a less skilled provider such as an aide, a massage therapist or an athletic trainer.
3. The expectation that the patient will experience significant recovery in a reasonable time frame.

Nagi’s Disablement Model is the preferred model that is disseminated in the Guide to Physical Therapy Practice. The Guide is the professional consensus of what constitutes the standard of physical therapy practice.

With these criteria in mind, let’s look at the SOAP note. What must go in the note?

Subjective
A dis-ability statement, or it’s converse – an ability statement such as the following:
· “I can’t get up out of a chair”
· “I can now get up out of a chair” (satisfies the expectation of improvement criteria)
Don’t use symptom language.
· “My leg hurts”
· “My back hurts’
Symptoms are included in the initial plan of care and, by definition, don’t change much day-to-day in rehabilitative services.

Objective
Numbers.
Measure something. Standardize the measurement. Make sure any other professional in your clinic could repeat the measurement.
· Measure range-of-motion using standardized movements.
· Measure strength using standardized measurements.
· Measure balance using standardized measurements
· Measure fear-avoidance beliefs using standardized measurements.
Make sure the measurements reflect patient-identified goals from the plan of care.

Numbers provide evidence of Medical Necessity for Physical Therapy, which is required in Medicare Progress Notes but not in daily Treatment Encounter Notes. If the daily notes meet the criteria for Progress notes then separate progress notes are not required.

Assessment
Did the patient meet the goal? Are they making progress towards the goals? Did the measurement get better?
· Goal #1 is met (satisfies the expectation of improvement criteria)
· Goal #2 is not met
· Goal #3 is updated. Increase Right Shoulder Flexion in Standing to 180o.

The Assessment also provides the physical therapist the chance to update the physical therapy diagnosis: the link between the patient-identified functional limitations and the measured impairments.

Physical Therapy Evaluation and Re-evaluation is an ongoing component of the skilled service. The initial diagnosis in the plan of care may change as new information is discovered by the physical therapist. The Assessment should be used to integrate the new information with the functional limitations to formulate an ongoing treatment diagnosis.
· Inability to raise the right arm overhead is due to a weak external rotator muscle
· Inability to walk across the parking lot is due to a stiff right hip, a weak right hip external rotator muscle and lumbar instability.
· Inability to descend steps is due to a weak right knee extensor, a right knee flexion contracture and a short calf muscle.

The Assessment should require critical thinking from the physical therapist. The Assessment cannot be done by any other service.

Plan
The Plan updates or changes the plan of care. Most of the time this is done monthly, not daily. The physical therapist updates the plan based on new findings, expected progress or both.

If the Plan is not changed or updated then there is no need to write anything in this portion of the SOAP note.

SIMPLE Template Data Collection

The 'how-to' videos are available at www.Physical-Therapy-Videos.com under the link 'Physical Therapy Diagnosis'.

This template is used for data collection.

The physical therapist puts the data into the plan of care and links the measured impairments to the measured functional limitations (using the OPTIMAL).

The data are impairments in ROM and strength that support the Medical Necessity for Physical Therapy.


SIMPLE Template
SIMPLE measurements-------Right Left Expected Normal (n=151)
1)Standing Trunk Sidebending--------------90 degrees
3)Supine FABER------------------------------22cm
4)Supine SLR----------------------------------65 degrees
5)Supine TKE----------------------------------0 degrees
6)Sidelying Hip External Rotation----------23cm
7)Sidelying Hip Internal Rotation-----------29cm
8)Sidelying Hip Extension------------------0 degrees
9)Sidelying Hip Abduction-----------------10 sec.
10)Sidelying Trunk Rotation----------------9cm

(note: this Word document renders poorly into Blogger so the columns for the Right/Left measurements do not show up well. For the PDF document in Word you can go to www.SimpleScore.com

SIMPLE diagnosis

Which measured values are lower than their expected normal values?

Which measured values are asymmetric?

Can you name the impaired motions?

Goal Setting

Improve [side, position, joint and motion] from [measured value] to [expected value].