An understanding of the disablement process as well as knowledge of the process of making informed clinical decisions based on evidence from the scientific literature are necessary foundations of comprehensive management of patients seeking and receiving physical therapy services. Provision of quality patient care involves the ability to make sound clinical judgments, solve problems that are important to a patient, and apply knowledge of the interrelationships among pathology, impairment, functional limitation, and disability throughout each phase of management. The primary purpose of this section of the chapter is to describe a model of patient management used in physical therapy practice. In as much as clinical reasoning and evidence-based decision making are embedded in each phase of patient management, a brief overview of the concepts and processes associated with clinical decision making and evidence-based practice are presented before exploring a systematic process of patient management in physical therapy. Relevant examples of the clinical decisions a therapist must make are highlighted within the context of the patient management model.

Clinical decision making refers to a dynamic, complex process of reasoning and analytical (critical) thinking that involves making judgments and determinations in the context of patient care. One of the many areas of clinical decision making in which a therapist is involved is the selection, implementation, and modification of therapeutic exercise interventions based on the unique needs of each patient or client. To make effective decisions, merging clarification and understanding with critical and creative thinking is necessary.A number of requisite attributes are necessary for making informed, responsible, efficient, and effective clinical decisions.

There is a substantial body of knowledge in the literature that describes various strategies and models of clinical decision making in the context of patient management by physical therapists. One such model, the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II), describes a series of steps involved in making informed clinical decisions.

The use of clinical decision making in the diagnostic process also has generated extensive discussion in the literature.To assist in and improve the decision-making process, tools known as “clinical prediction rules,” first developed in medicine, now are being developed and used by physical therapists. Some clinical prediction rules contain predictive factors that help a practitioner establish specific diagnoses or prognoses, whereas others identify subgroupings of patients most likely to benefit from a particular approach to treatment. Among others, prediction tools have been developed to assist in the diagnosis of deep vein thrombosis and ankle fracture after an acute ankle injury,as well as to identify patients with low back pain, who are most likely to respond to stabilization exercises.An additional focus of ongoing study and discussion is the comparison of clinical reasoning of expert versus novice therapists.

Requirements for Skilled Clinical Decision Making During Patient Management
• Knowledge of pertinent information about the problem(s)
• Prior clinical experience with the same or similar problems
• Ability to recall relevant information
• Cognitive and psychomotor skills to obtain necessary knowledge of an unfamiliar problem
• Ability to integrate new and prior knowledge
• An efficient information-gathering and information-processing style
• Ability to obtain, analyze, and apply evidence from the literature
• Ability to critically organize, categorize, prioritize, and synthesize information
• Ability to recognize clinical patterns
• Ability to form working hypotheses about presenting problems and how they might be solved
• An understanding of the patient’s values and goals
• Ability to determine options and make strategic plans
• Use of reflective thinking and self-monitoring strategies to make necessary adjustments

Health care continues to move in the direction of physical therapists being the first contact practitioners through whom consumers gain access for services without physician referral. Hence, the need to make sound clinical judgments supported by scientific evidence during each phase of patient management becomes more and more essential for physical therapy practitioners.

Buy the Book that holds this excerpt: Therapeutic Exercise: Foundations and Techniques (Therapeutic Exercise: Foundations & Techniques)

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