Untitled Lesson

©2021 Mayo Foundation for Medical Education and Research | slide-1

CLINICAL DECISION-MAKING &
INITIAL EVALUATION COMPONENTS
PROFESSIONAL MANAGEMENT II
PT 6380
JOY MACHEEL, PT, DPT, CWS, CLT-LANA
BOARD CERTIFIED CLINICAL SPECIALIST IN ONCOLOGY
PHYSICAL THERAPY

©2021 Mayo Foundation for Medical Education and Research | slide-2

INITIAL EVALUATIONS

• Paint a picture!

• Formatting based on ICF model & APTA Guide to
Physical Therapist Practice

• Assumptions:
Documentation shapes and reflects clinical reasoning
• Enablement model provides framework for clinical
reasoning
• Documentation should be based on functional
outcomes

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Multiple Select

L5 disc bulge

• Medical

• Physical Therapy

Multiple Select

Low back pain

• Medical

• Physical Therapy

©2021 Mayo Foundation for Medical Education and Research | slide-3

CHECK YOURSELF

• What is a functional outcome?

Open Ended

What is a functional outcome?

©2021 Mayo Foundation for Medical Education and Research | slide-3

CHECK YOURSELF

• What is a functional outcome?

©2021 Mayo Foundation for Medical Education and Research | slide-4

INITIAL EVALUATION FORMAT

• Reason for Referral

• Activities

• Impairments

• Assessment

• Goals

• Plan of Care

©2021 Mayo Foundation for Medical Education and Research | slide-5

©2021 Mayo Foundation for Medical Education and Research | slide-6

ICF MODEL

Disorder/Disease

Contextual
Factors

Impairments:

Limitations

Restrictions

©2021 Mayo Foundation for Medical Education and Research | slide-7

INITIAL EVALUATION FORMAT

• Reason for Referral

• Activities

• Impairments

• Assessment

• Goals

• Plan of Care

©2021 Mayo Foundation for Medical Education and Research | slide-8

PATIENT/CLIENT MODEL

• Examination

• Evaluation

• Diagnosis

• Prognosis

• Intervention

• Outcomes

©2021 Mayo Foundation for Medical Education and Research | slide-9

PATIENT/CLIENT MODEL + INITIAL EVAL FORMAT

• Examination

• Evaluation

• Diagnosis

• Prognosis

• Intervention

• Outcomes

• Reason for Referral

• Activities

• Impairments

• Assessment

• Goals

• Plan of Care

©2021 Mayo Foundation for Medical Education and Research | slide-10

INITIAL EVALUATION – DIAGNOSIS

• May be different from medical diagnosis

• “Causes of specific problems that PT or PTA will address
in the intervention strategy”

• Includes information about health condition
• Nature
• Location
• Etiology
• Link between impairments and limitations

©2021 Mayo Foundation for Medical Education and Research | slide-11

INITIAL EVALUATION – DIAGNOSIS

• Medical vs. Physical Therapy Diagnoses
• “Physicians primarily classify the causes of disease,
disorders, and injury, whereas physical therapists
primarily classify the consequences that result from
them.”

• We are movement science experts!
• Movement system impairments, functional limitations,
or disabilities
• Treatment of dysfunction vs. treatment of disease
• PT Diagnosis = functional diagnosis