Discussion Physical Therapy

The ICF provides clinicians with standardized termi-

nology and a framework to aid in exploring the impact of disease or injury on an individual’s daily life. More spe- cifically, physical therapy providers can use the ICF to help understand the consequences of the disease or condition on the body systems and the impact on the individual’s activ- ity level and participation within society. Consideration

of disablement when working with patients helps physical therapy providers to realize more complex functional and social issues that patients face.

Individuals in need of physical therapy services often have a disease or injury with resulting impairments in body structure(s) and/or function(s), activity limitations, and participation restrictions that are identified during the physical therapist’s examination. Impairments can be limitations in range of motion, strength, endurance, or balance, to name a few. But to see how the patient’s abil- ity to participate in society has been compromised, the examination must go beyond the impairment level. It is our responsibility to understand how impairments affect the patient’s day-to-day activities and participation in a variety of settings and situations; therefore, the physical therapist’s examination of patient function includes assessment of the following: (1) activities such as bed mobility, transfers, hygiene, self-care, and home management (eg, yardwork, household cleaning); and (2) participation such as the abil- ity to work, go to school, play, and participate in commu- nity activities (eg, going to the grocery store or bank). By understanding an individual’s impairments and his or her activity limitations and participation restrictions, we can better understand the degree of disability associated with the pathology for the individual patient. Discussion Physical Therapy

Figure 1-2. The International Classification of Functioning, Disability and Health3 from the WHO. (Reprinted with permis- sion from the WHO.)

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Disablement and Physical Therapy Documentation 5

DOCUMENTATION AND DISABLEMENT Documentation, otherwise known as medical record

keeping, has been defined as “any entry into the individu- al’s health record, such as a(n) consultation reports, initial examination reports, progress notes, flow sheets, checklists, re-examination reports, or summations of care, that identi- fies the care or services and the individual’s response to intervention.”8 Complete documentation also includes the physician prescription(s) and certification(s), communica- tion with other care providers, copies of exercise programs or patient instructions, and any other disciplines’ notes or comments that support the interventions.9

As you will read in subsequent chapters, documenta- tion will serve many purposes, but, regardless of the pur- pose, your documentation should reflect disablement. One reason for integrating disablement concepts in physical therapy documentation is to achieve consistency in termi- nology because our notes are the sole record of the episode of care provided to each patient or client. Another reason is to show the reader how the patient’s pathology and impair- ments influence his or her activities and participation in daily life. Disablement concepts serve as a foundation for this text. Throughout the chapters, you will be reminded of the following 3 important disablement concepts that should be integrated into your clinical documentation: 1. Documentation should reflect not only measures of

impairment, but also measures of activity limitations and participation restrictions.

2. Documentation should describe how the patient’s impairments relate or contribute to his or her activity limitations and participation restrictions.

3. Documentation should explain how physical therapy interventions are bringing about changes in impair- ments, activity limitations, and participation restric- tions that relate to the patient’s therapy goals. Discussion Physical Therapy

REFERENCES 1. MacDermid JC, Law M, Michlovitz SL. Outcome mea-

surement in evidence-based rehabilitation. In: Law M, MacDermid JC, eds. Evidence-Based Rehabilitation: A Guide to Practice. 3rd ed. Thorofare, NJ: SLACK Incorporated; 2014:65-104.

2. Verbrugge LM, Jette AM. The disablement process. Soc Sci Med. 1994;38(1):1-14.

3. World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization; 2001.

4. American Physical Therapy Association. International Classification of Functioning, Disability, and Health. APTA Website. http://www.apta.org/ICF/. Updated August 23, 2013. Accessed October 24, 2016.

5. Madden R, Sykes C, Ustun TB. World Health Organization Family of International Classifications: definition, scope, and purpose. World Health Organization Website. http://www. who.int/classifications/en/FamilyDocument2007.pdf?ua=1. Updated February 2, 2012. Accessed October 24, 2016.

6. World Health Organization. Classifications: International Classification of Disease. WHO Website. http://www.who. int/classifications/icd/en/. Updated June 29, 2016. Accessed October 24, 2016.

7. Escorpizo R, Bemis-Dougherty A. Introduction to spe- cial issue: a review of the International Classification of Functioning, Disability and Health and physical therapy over the years. Physiother Res Int. 2015;20(4):200-209.

8. American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. APTA Website. http://guidetoptprac- tice.apta.org/content/1/SEC2.body. Updated August 1, 2014. Accessed October 24, 2016.

9. Redgate N, Foto M. Pay by the rules: avoid Medicare audits and reduce payment denials with a sound strategy and prop- er documentation. Physical Therapy Products. 2003;October/ November:28-30. Discussion Physical Therapy

 

 

Chapter 16

REVIEW QUESTIONS 1. How is a person’s health determined today as opposed to 5 decades ago?

2. In your own words, describe disablement.

3. According to the ICF, what is the difference between an impairment, an activity limitation, and a participation restriction?

4. Why is there a need for disablement models today? Why are they important to you?

5. What is physical therapy documentation? What does it include?

6. Give some examples of ways a physical therapist assistant can incorporate disablement concepts into his or her documentation.

7. Look at the examples below. Determine if each would be considered an impairment in body function or structure, an activity limitation, or a participation restriction.

Taking a bath Going to school Brushing teeth Limited shoulder motion Walking in the community Going to the grocery store Ascending/descending stairs Turning a door knob Poor endurance Writing Working Poor balance Donning socks Bathing Discussion Physical Therapy

 

 

Disablement and Physical Therapy Documentation 7

Read the following scenarios and identify the impairments, activity limitations and participation restrictions.

8. You are working with a 70-year-old male who had a total hip replacement 3 weeks ago. He is now able to move in and out of the bed independently, transfer to a chair placed at the bedside, and ambulate 25 feet with a standard walker. He wants to return to driving, golfing, and playing with his grandchildren.

9. You are working with a 10-year-old female in the school system. Her medical diagnosis (pathology) is spastic diple- gia cerebral palsy. You have been working on ambulating up and down the stairs (which she can perform with min- imum assist of 1, a quad cane, and a handrail) and increasing the speed of her gait. At the present time, she leaves her classes early so that she can make it to the next one on time, and she uses the elevator rather than the stairs.

10. Your patient is a 15-year-old who sustained a traumatic closed head injury in a motorcycle accident. He is confused and disoriented, and he requires constant supervision for his safety. He can walk and get in and out of bed with supervision. He can also ascend and descend stairs with supervision. He is unable to work.

Rebecca McKnight, PT, MS

Erickson ML, McKnight R. Documentation Basics for the Physical Therapist Assistant, Third Edition (pp. 9-18) Discussion Physical Therapy