Clinical: Lecture 1
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What is occupational therapy?
- 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
What is physical therapy?
- 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
What's the difference between occupational and physical therapy?
physical therapy works on physical skills and movement, while occupational therapy applies those skills and movements to activities that "occupy" our days
What distinguishes PT and OT practitioners from technicians?
- 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
How will we decide which rehabilitation aim(s) will result in the best outcome for our patient/clients?
we'll follow a defined clinical reasoning process to end up with a defensible decision
What is clinical reasoning?
- 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?"
Why is clinical decision-making important?
- 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
CDM's from either discipline provide a framework on which we can:
- 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
OT framework: Encourages valuation of often overlooked elements including:
- cultural environments
- physical environments
- social environment
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
The meaning of cultural environments being overlooked for practitioners:
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
What is the meaning for practitioners, if physical environments are overlooked?
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
What does it mean for practitioner to overlook roles?
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?"
What is step one of Clinical Reasoning Model?
figure out a way to apply these overarching theories in everyday patient care
hypothesis oriented algorithm for clinicians II
What are the basic steps of HOAC II
- examination (includes interview)
a label encompassing a cluster of signs and symptoms, syndromes, or categories. It is the decision reached as a result of the diagnostic process
The PT diagnostic process describes the __________ and ________:
- 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
OT: occupational profile=
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
Analysis of occupational performance:
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
OT: intervention plan=
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 OT diagnostic prcoess describes:
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
OT: intervention implementation-
skilled process of effecting change in the client's occupational performance leading to engagement in occupations or activities to support participation
OT: intervention review:
continuous process for reevaluating and reviewing the intervention plan, the effectiveness of implementation, the progress toward targeted outcomes
1. collect initial data
- interview (examination)
- chart/written records review
- info from family (if needed)
- info from other caregivers
- non-verbal info
- occupational profile info gathering
2. List of problems
- patient-identified (PIP)
- Non-patient (therapist/family) identified (NPIP)
3. Formulate examination strategy
- look at problem list
- prioritize with patient
- identify how you will examine the depth and breadth of the problem
4. examine (and narrow) the problems list by a(n):
- 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)
5. Setting goals; planning f/u
- 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
There should never be an intervention that is not related to a:
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
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