This extra step in your clinical thought process can dramatically improve your notes and charts for your Medicare compliance program.
The simple act of linking the measured impairment to the patients' activity limitation is one of the essential skilled components of physical therapist practice.
For example:
“Improve sidelying hip external rotation from 15cm to 25cm in order to improve OPTIMAL Balance from 4/5 to 2/5.”Your clinical rationale is explicit in the goal – without the need for additional statements clarifying the link between measured impairments (hip external rotation) and patient activity limitations (balance).
Your physical therapy diagnosis may change from body part to body part and from activity to activity.
For example, the same patient may have the following goal:
“Improve AROM ankle dorsiflexion from 0 degrees to 10 degrees in order to improve OPTIMAL Stairclimbing from 4/5 to 2/5.”
Diagnosis differences
The interesting thing is that our diagnosis is not predicated on any medical model.
In the examples above, the written reason for patient referral was the following:
‘lumbar strain’ – ICD-9 code 722.93 (Other and unspecified disc disorder, lumbar region).
The physical therapist independently identified the two above mentioned areas above that needed attention that could not be consistently predicted by the medical diagnosis.
The ICF model, on the other hand, more accurately identifies the work and the decisions made by the physical therapist.
A physical therapist might diagnose, using these ICF codes, the activity limitations and impairments in body structure and function.
| ICF Domain | ICF descriptor | ICF code |
|---|---|---|
| Activity | Walking on different surfaces | d4502 |
| Body structure | Muscles of ankle and foot | s75022 |
| Body function | Mobility of a single joint | b7100 |
Using a disablement model as the decision-making framework and making the commitment to always diagnose every patient the physical therapist is freed from the subservient, technical position in the medical model.
The physical therapist is put in the position of making decisions that are in the best interests of the patient, based on the finding from the physical therapy evaluation.
No other professionals are examining patients at this level:
- not physicians
- not chiropractors
- not massage therapists
- not athletic trainers.
Decision-making and the physical therapists’ diagnosis are the sustainable competitive advantage of physical therapy over all of these other professions in the care and rehabilitation of our patients.
Put your diagnosis in your goals to improve your written work.
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