Consultation, Screening and Delegation in Physical Therapy - Case Study Example

Insert Insert Insert 4 February Consultation, Screening and Delegation in Physical Therapy Supervision Scenario Case 1 This case presents a fifty-year-old man having sustained a significant tear to his rotator cuff. Following an initial surgical repair, referral for physical therapy (PT) included a passive ROM thrice a week for two weeks, a supervised home program of active exercise for two weeks and external resistance exercises for external and internal rotation every day for a month. However, the patient performed unsupervised home exercises contrary to the physician’s prescription. In addition, he engaged in sports activities despite instructions to discontinue. However, the physical therapist (PT) initiated three weeks’ therapeutic exercises along with addition of free weights. On the final PT visit, the PTs delegates supervision to the athletic trainer clinic manager whose actions during the intervention causes reinjury to the patient accompanied with severe pain in the repaired site. A second surgery repairs the rotator cuff. Florida’s PT practice act requires practicing PT practitioners to meet the minimum requirements for safe practice. Thus, those presenting danger to patients or falling below minimum competency should be prohibited from practice according to Florida Physical Therapy statutes and rules as outlined in the legislative intent of Chapter 486. The PT involved the athletic trainer clinic manager in supervising and acting during intervention contrary to the requirement of using a PT assistant (PTA) as stated by the practice act. Moreover, the PT remained absent to offer direct supervision for direction of actions and consultation when the patient felt popping noise and severe pain in his shoulder. The unsupervised home exercises undertaken by the patient do not match the act requirement for physical therapy assessment involving licensed PT. The act also requires licensed PT to be of noble moral character unlike the remark made by the athletic trainer when the patient complained of severe pain (The Florida Legislature, n.d.). Similarly, American Physical Therapy Association (APTA) guidelines provide resources and support to its members in establishing and sustaining efficient physical therapy practices in diverse settings. Adequate knowledge and appropriate skills in the administration and management of practice remain essential for APTA members whether practicing as an employee, owning a practice, managing a facility, or directing a department. Moreover, clinical knowledge and an understanding of problems or concerns remain fundamental to effective patient care in enabling physical therapy practice and impact on care delivery. APTA provides various rules and regulations as regards the scope of work, supervision and role of both PTs and PTAs in the provision of PT services and supervision (APTA, 2009). In this case, the PT assumed a general supervision, one of APTA’s levels of supervision, but did not remain available by telecommunication. This stays evident as the athletic trainer never engaged in telecommunication of any kind and upon the PT return, an explanation and further direction is provided to the patient regarding the pain and popping noise. Hence, communication remained absent during the general supervision practice of the final scheduled visit and in this regard direction could not be attained immediately in intervening the pain. Lack of telecommunication in this case indicates lack of teamwork in delivery of care to the patient. Furthermore, APTA makes provisions for procedural interventions exclusively performed by PT for interventions requiring instant and continuous checkup and evaluation all through the intervention. The patient’s situation required the PT’s immediate and continuous procedural intervention since the patient had sustained a significant tear on his rotator cuff, which necessitates careful manual therapy when stretching the shoulder and the arm. Lastly, the actions and remarks of the athletic trainer to the patient do not reflect APTA’s prerequisite of an understanding on the problem in addition to the possession of essential clinical knowledge. Supervision Scenario Case 2 In this case study, a sixty year old man undergoes an uncemented total hip arthroplasty. Upon discharge, the discharge note delivered to the health care agency indicated “weight bearing as tolerated” contrary to the physician’s recommendation for home PT with an initial “toe touch weight bearing” ambulation. However, the home care agency subcontracts a PT who delegates therapy intervention to a PTA both of private PT practice. The PTs’ plan of care excludes the nature of the hip prosthesis, specific limitation on weight bearing status of the patient’s operated leg and an awareness of the incorrectly translated hospital discharge referral note. In this regard, the PTA employs care progression meant for a cemented hip. The patient complains of swelling and continuous soreness and neither the PTA nor the PT discuss or reassess the patient’s status and care. Also, the physician failed to document the patient’s abnormal progress despite his periodical follow ups thus gives discharge for home exercise program which lasts almost a year without improvement. The second arthroplasty leads to infection necessitating for the third surgery which the physician attributes to aggressive weight bearing progression in initial PT. Florida’s practice act requires that patient related interventions performed by PTAs remain under the onsite supervision of a licensed PT. However, in this case study; the PT delegates the activities to a PTA who carries out the interventions for the patient without the PT’s onsite supervision. This also becomes evident when the PT pays his initial visit after six weeks with no written record on reassessments done, the patient’s status and care progression as well as a discussion of the patient’s progress with the PTA. The PT also implements a plan of treatment for the patient contrary to the requirement indicated for patients currently under treatment in a licensed facility following Chapter 395. Furthermore, the PT fails to document the patient’s information regarding the status of weight bearing and hip prosthesis as well as the incorrectly translated discharge instructions necessary for initiating the appropriate plan of care for the patient. Hence, the initial aggressive weight bearing progression becomes attributed as the cause of subsequent surgeries (The Florida Legislature, n.d.). APTA’s model for PT/PTA teamwork in delivering patient care outlines policies guiding the scope of work for PTAs and the level of supervision PTs ought to provide. According to APTA guidelines, PT interventions that entail clinical decision making should be provided by PTs only whereas PTAs provide selected interventions under the PT’s direction and no less than general supervision. In addition, PTAs or PTs must maintain direct contact with patients during each intervention session. Converse to these requirements, the PTA became mandated to provide all interventions for the patient with no general supervision by the PT. Moreover, the PTA exercised clinical decision making in selecting a care progression for the patient since the plan of care lacked the necessary information. The PT never interpreted the patient’s referral in addition to not documenting the discharge summary and establishing the discharge plan (APTA, 2009). Following his initial visit to the patient, after six weeks of therapy, the PT does not modify the plan of care based on reexamination of the patient as well as PT goals and results taking into account the patient’s complaints of swelling and continuous soreness. An omission of all documentation for interventions offered to the patient remains evident throughout the intervention process by the PT, PTA and referring physician. During offsite supervision, the PT stayed inaccessible by telecommunication and not any repeatedly scheduled and documented discussions with the PTA became apparent. Also, the patient undertakes an independent home exercise program for six months without direct contact of the PT or PTA. Consequently, the patient undergoes a two more arthroplasty on his leg. References American Physical Therapy Association. (2009). Retrieved from http://www.apta.org/ Practice and Patient Care/ Practice Administration/ Supervision and Teamwork. The Florida Legislature. (n.d.). The 2010 Florida Statutes (including Special Session A): Physical Therapy Practice (Chapter 486). Retrieved from http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400 0499/0486/0486.html Read More