Clinical: Lecture 1

• occupational therapy enables people to do the day-to-day activities that are important to them...
• ...despite impairments, activity limitations, or participation restrictions or despite risks for these problems

• focuses first on prevention, and then on the restoration of function and movement after injuries or disabilities
• therapeutic exercise and functional training are cornerstones of PT treatment

physical therapy works on physical skills and movement, while occupational therapy applies those skills and movements to activities that "occupy" our days

• our patient care decisions shows clear and defensible clinical reasoning as required by COE
• patient instruction emphasizes why along with what
• we accept a higher responsibility to inform and protect the public

we'll follow a defined clinical reasoning process to end up with a defensible decision

• the cognitive processes that underlie the rehabilitation process
• allows therapist to justify choices when asked, "What made you choose action A instead of action B?"

• patient
• payer
• professionalism

• not enough to do what we think is right for the situation...it must be right
• we police ourselves by examining what we do
• providing a logical train of thought to link the "why" to the "what" in daily patient care supports our claim that we are professionals and not technicians

Clinical Reasoning Model

• interpret information we gather about the person, their environment, occupation, chief concerns and hopes
• identify those standardized examination procedures which will allow us to determine the cause of the person's concerns and explore its impact on their life
• evaluate/assess/develop results of our interview/examination into a working hypothesis that furthers our knowledge of the patient's condition
• communicate all information in a logical manner so it's easy to involve patients in all decisions about their options and their role in the recovery process

• cultural environments
• physical environments
• social environment
• roles

customs, beliefs, activity patterns, behavior standards, and expectations accepted by the society for which the individual is a member; includes political aspects, such as laws that affect access to resources and affirm personal rights and opportunities for education, employment, and economic support

underscores importance of community to which the patient must return after leaving us and reminds us to explore its influence on their goals and desires in rehab

non-human aspects of context including accessibility to and performance w/in environments having natural terrain, plants, animals, buildings, furniture, objects, tools, or devices

ask probing questions to understand patient's lives

availability and expectations of significant individuals, such as spouse, friends, and caregivers. ...includes larger social groups which are influential in establishing role expectations, and social routines

include, but are not limited to, those related to family, work, community. One's responsibilities define the nature of occupational performance at various points in one's lifespan

we need to ask: "who will help you when you are not w/ us? and probe to see if the patient is aware of available community resources. Look beyond the physical 'type' of your patient to ask: "who were you? would you still be that person if you could? what else would you take on if you could? What can you let go of w/out missing it?"

figure out a way to apply these overarching theories in everyday patient care

hypothesis oriented algorithm for clinicians II

• examination (includes interview)
• evaluation
• diagnosis
• prognosis
• intervention
• outcome

a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the decision reached as a result of the diagnostic process

• origin of the patient's problem
• impact of the problem on the person's life

• final results of a course of care that was planned to assist the patient to achieve as much as the prognosis, premorbid condition, personal expectations, and motivation suggest is possible
• --outcome is NOT a synonym for the patient's status when care happens to end. Outcomes are established based on the literature, patient desires, and professional expertise

therapist's predicted optimal level of improvement in function and amount of time needed to reach that level

purposeful and skilled interaction of the therapist with the patient and, when appropriate, with others involved in patient care, using procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis

the initial step in evaluation process that provides an understanding of the client's occupational history and experiences, patterns of daily living, interests, values, and needs

specific tools, instruments, tests, or interactions that occupational therapists use during the evaluation process

OT uses the term occupational performance problem with a top down reasoning approach that looks at what a patient can do and how closely that matches what they want/need to do or are expected to do

outline of selected approaches and types of interventions, which is based on the results of the evaluation process, developed to reach the client's identified targeted outcomes

the origin of the patient's problem and the impact of the problem on the person's life. Its scope goes beyond a medical diagnosis

skilled process of effecting change in the client's occupational performance leading to engagement in occupations or activities to support participation

continuous process for reevaluating and reviewing the intervention plan, the effectiveness of implementation, the progress toward targeted outcomes

• interview (examination)
• chart/written records review
• info  from family (if needed)
• info from other caregivers
• non-verbal info
• occupational profile info gathering

• patient-identified (PIP)
• Non-patient (therapist/family) identified (NPIP)

• look at problem list
• prioritize with patient
• identify how you will examine the depth and breadth of the problem

• review of all systems/in-depth examination of targeted systems/red flag screening
• occupational analysis
• revisit interview or examination with more questions if you missed something

create final list of problems, including issues related to physical, cognitive, psychosocial, societal limitations (more evaluation occurs in context of prognosis to result in diagnosis)

• goals set with patient's input if adherence is desired
• progress monitored daily but need to use guides to identify when enough change should occur that patient's condition will show measurable improvement/no change/decline

• decide whether patient needs hands-on, skilled service or home program or both
• provide rationale for decision whether to delegate to assistant
• clearly match each goal to a problem from the list and each goal/problem to an intervention

problem and a goal

the process of obtaining a history (interview), performing relevant systems reviews, and selecting and administering specific tests and measures to obtain data

• entire information gathering process used to make intervention decisions. It is a dynamic process in which the therapist makes clinical judgments based on data gathered during the examination
• for OTs it combines the Occupational Profile with the Analysis of Ocuupaitonal performance

international classification of Function model