Clinical Evaluation and
Assessment Principles in
Orthotics and Prosthetics
John N. Billock, CPO
ABSTRACT
Clinical evaluation and assessment of
a patient's orthotic or prosthetic needs is
largely a post-education skill that develops and improves with experience. Unfortunately, evaluating and assessing a
patient's needs has not traditionally been
included in the formal education of
most O&P practitioners Until recently,
it truly was a skill practitioners had to
develop with clinical experience. However, the O&P professional practicing in
today's healthcare environment is called
upon to render and document specific
recommendations for O&P care.
Since O&P is both a clinical and technical science, a practitioner's procedures
for assessing, evaluating and documenting must be sufficient to appropriately
determine a patient's specific need for
O&P service. The process a practitioner
uses to clinically assess and evaluate a patient's needs must justify the need for
O&P services.
This article addresses the key elements
of the clinical assessment and evaluation
of a patient needed for the documentation and justification of O&P services.
Introduction
Sound clinical evaluation and assessment skills have become critical for
orthotic and prosthetic (O&P) practitioners who must appropriately document their patients' needs in today's
healthcare environment. The days of
providing O&P services strictly under
the direction of a physician have diminished as the medical education and
clinical skills of O&P practitioners
have advanced. Additionally, expanding medical technology, along with the
advancing complexities of orthotic and
prosthetic practice and technology,
have made it nearly impossible for today's physicians to take "sole responsibility" for determining the most appropriate O&P care for any given patient.
Increasingly, physicians and other allied healthcare providers have come to
rely on the professional skills of qualified O&P practitioners to assess and
evaluate the particular orthotic or prosthetic needs of a patient and make the
appropriate recommendations for
treatment. The trends toward quality assurance and outcomes-oriented healthcare have led to a growing need for specific documentation of an individual's
orthotic or prosthetic needs.
In recent years, the healthcare reform initiatives and the growing movement toward managed care have advanced the requirement for concise
documentation of O&P medical necessity. The requirement has become increasingly common for all levels of
O&P care, whether it be a simple or
complex comprehensive orthotic or
prosthetic service.
Understanding the basic elements of
the patient assessment and evaluation
process is critical to achieve consistent
conclusions and offer recommendations that are backed by documentation justifying a specific need or level of
O&P care. Without this understanding,
the composition and structure of a
well-prepared evaluation and/or consultation report can become confusing.
Additionally, the quality and timeliness
of care can be adversely affected if documentation is not well-presented and
understood by payers.
This article attempts to identify the
basic elements of an appropriate evaluation and assessment as it relates to the
practice of providing comprehensive
O&P services. The basic elements of a
well-structured evaluation and/or consultation report also are identified.
Evaluation and Assessment Principles
A clinical evaluation and assessment is
an examination or review of a patient's
medical needs that leads to an appraisal of his/her condition and an
opinion for treatment. In most cases,
the review process begins on the initial
encounter with a patient, which usually
occurs once the patient has been referred by an attending or consulting
physician. In today's healthcare environment, however, referrals also are increasingly being made by third-party
payers and other managed-care providers.
The extent of an evaluation and assessment depends on the complexity of
the patient's diagnosis and urgency for
care or treatment. Further, the extent
of an appropriate evaluation and assessment may involve only the initial
visit, or a series of visits, to reach a specific conclusion as to the most appropriate O&P care or treatment.
Elements of an Evaluation and Assessment
A thorough clinical evaluation and assessment, followed by an appropriate
consultation report, should include the
following elements: I) review of primary diagnosis; 2) review of current medical history; 3) review of past medical
history; 4) review of current and past
O&P history; 5) physical examination;
6) findings; 7) impressions; 8) conclusions; and 9) recommendations (see
Table A
).
Review of Primary Diagnosis
A comprehensive understanding of the
patient's primary diagnosis as it relates
to the need for O&P services is essential in determining the most appropriate
care. Understanding the possible effects
and/or complications created by other
secondary diagnoses is just as essential
in determining appropriate care. Depending on the knowledge and skill of
the O&P practitioner, consultation with
the referring physician or other attending physicians often is necessary to clarify and confirm any potential negative
effects of the O&P services being
considered.
Review of Current Medical History
A review of the patient's current medical history as it relates to the patient's
primary diagnosis or secondary diagnoses is an essential part of a competent clinical evaluation and assessment.
This particular review provides essential medical information and background regarding the current status of
the patient and can help predict the patient's rehabilitation potential.
The current medical history may be
derived from several sources. Verbal or
written communication from the referring or other attending physician and/or
another referral source provides an
initial opportunity to gather important
information regarding the patient's
condition specific to his/her need for
O&P services.
If the patient is seen in a hospital or
other healthcare setting, key elements
of his/her medical status also may be
derived through direct communication
with other healthcare providers. Additional information usually is contained
within the patient's medical records
maintained by the facility. The file may
include pertinent information found in
an Admission History and Physical
Consultation Report, Surgical Report
Radiographic Report, Therapy Report
Rehabilitation Treatment Plan, or Hospital Discharge Summary. Also, where
available, a Social Services and Vocational Rehabilitation Report can provide valuable background information
All of these documents contain data
that can help determine the most appropriate O&P care to be provided.
In addition, depending on the patient's cognitive status and understanding of his/her overall medical condition
his/her personal input (or that of
knowledgeable family member) can
vital to the evaluation and assessment
process.
Review of Past Medical History
A review of the patient's past medical
history related to the primary or secondary diagnoses will provide additional pertinent information regarding the
patient's medical status and need for
O&P services. Past medical history may
be derived from several of the same
sources previously described, including
past hospital or healthcare facility medical records and personal input from
the patient or family member.
Review of Current and Past
O&P History
A review of current and past O&P history with the physician, patient and/or
family member, along with a review of
available O&P records, can prove important to the overall care recommend
ed and provided. Obtaining a profusion
of information is especially significant
the patient has previously encountered
complications or inappropriate O&P
care. Again, depending on the patient's
cognitive status and understanding of
his/her overall medical condition, his/
her personal input (or the input of
knowledgeable family member) may be
important to the evaluation and assessment process.
Physical Examination
An appropriate physical examination
consistent with the patient's diagnosis
and need for the O&P services is critical to the potential outcome of the care
to be provided. This element of the clinical evaluation and assessment requires
the clinical skill and professional
knowledge of an appropriately trained
and qualified practitioner.
An O&P practitioner must have excellent clinical abilities to properly
evaluate and assess the physiological
and pathomechanical needs of a patient consistent with his/her diagnosis
and medical history. Determining the
appropriateness and extent of an individual's need for comprehensive O&P
services requires thorough knowledge
of the patient's medical condition and
any complications associated with
his/her musculoskeletal, neuromuscular and/or vascular system.
Additionally, recognizing the effects
or potential effects of existing physical
limitations as they relate to the patient's
vocational and/or avocational interests
is critical to the overall evaluation and
assessment of the patient. This becomes
particularly important when the patient
requires comprehensive O&P services.
Equally important in many cases is the
practitioner's understanding of the patient's psychological status and its overall importance to his/her orthotic or
prosthetic treatment, recovery and/or
rehabilitation potential.
In the most basic sense, an appropriate orthotic or prosthetic physical examination should include neuromuscular
and/or musculoskeletal evaluations.
These evaluations should include an assessment of range of motion, muscle
strength and/or weakness, pain, sensory
and motor nerve paralysis, joint stability, and soft tissue condition. In some
cases, the patient's balance and stability
during gait also should be evaluated
and assessed.
Additional aspects of a physical
examination may include specific evaluation and assessment procedures consistent with a particular diagnosis. An example of this is an assessment of fine
motor prehension grasp and release for an individual with upper-limb paralysis under consideration for a functional wrist/hand orthosis. Another example is
an assessment of muscle EMG surface
potential for an individual with an upper-limb amputation under consideration for a functional myoelectrically
controlled hand prosthesis.
Findings
The findings of the evaluation and assessment process identify the specific
results of a physical examination as
well as any underlying diagnosis and/or
disability. The findings become the documentation that verifies the effects of
the diagnosis and/or disability. The findings must be adequately supported
and/or verified by the results of the general and specific physical examinations.
The findings also must lead to realistic
impressions of the needed O&P care
and the conclusions that must support
subsequent recommendations for care
and management.
Impressions
The impressions are initial opinions
provided by the practitioner that state
or support the anticipated need or outcome expected from the O&P treatment being considered. They should
include an opinion concerning the
patient's responsiveness, or potential
responsiveness, to the care being considered. The impressions must support
the findings and lead to justifiable conclusions.
Conclusions
The conclusions summarize the practitioner's findings and impressions. More
importantly, they must confirm or identify the specific need(s) for O&P care
and management and identify anticipated outcomes. The anticipated outcomes
must be consistent with the findings and
impressions. They also must provide
unquestionable support of the overall
need for O&P services consistent with
the patient's diagnosis and the findings
of the physical examination.
Recommendations
The recommendations are drawn from
the conclusions and must lead to a specific statement of the type and/or level
of O&P services required for the appropriate care and treatment of the patient. They also must be supported by
the findings of the physical examinations and be consistent with the impressions and conclusions reached. More
importantly, the recommendations
must be consistent with the underlying
diagnosis or diagnoses and lead to the
desired outcomes expressed or implied
in the impressions and conclusions.
The recommendations should specify any additional O&P assessment and
evaluation procedures needed. When
definitive recommendations are being
rendered, they should specifically describe the type and design of the recommended orthosis or prosthesis. Further, they should be consistent with any
supporting documentation required by
state or federal regulatory healthcare
agencies.
If the referral source or the patient
has asked to review the recommendations, the practitioner should accommodate the request before proceeding
with providing further services. Third-party payers or agencies involved in the
authorization of O&P healthcare services also may require a review and approval process.
Evaluation and Assessment Visit
Classifications
An evaluation and assessment visit can
be described as minimal, brief, limited,
intermediate, extended or comprehensive, depending on its complexity and
the duration of the visit.
- Minimal: The patient's condition
requires an evaluation and assessment
that is minimal in duration and requires
minimal documentation stating the
need for O&P care. Generally, this routine requires only one initial visit and
does not require verbal consultation
with the referring physician or referral
source.
- Brief: The patient's condition requires an evaluation and assessment
that is brief in duration and requires
only limited documentation stating the
need for O&P care. Generally, this
asessment requires only one initial visit
and may or may not involve verbal consultation with the referring physician or
referral source.
- Limited: The patient's condition requires an evaluation and assessment
that is limited in duration and requires
intermediate documentation of the
need for O&P care. Generally, this assessment requires only one initial visit
and may involve a verbal or written
consultation with the referring physician or referral source.
- Intermediate: The patient's condition requires an evaluation and assessment that is intermediate in duration
and requires extensive documentation
of the need for O&P care. Generally,
only one initial visit is required and involves at least one verbal and/or written consultation with the referring
physician or referral source.
- Extended: The patient's condition
requires an evaluation and assessment
that is extended in duration and requires comprehensive documentation
of the need for O&P care. Generally,
only one initial visit is required, and it
involves verbal and/or written consultations with the referring physician or
referral source.
- Comprehensive: The patient's condition requires an evaluation and assessment that is comprehensive in duration
and requires complex documentation
of the need for O&P care. Generally,
more than one initial visit is required,
and the practitioner provides more than
one verbal and/or written consultation
with the referring physician or referral
source.
The previous categories and descriptions of the types of evaluation and
assessment visits are modeled, in part,
after the American Medical Association 's Physicians' Current Procedural
Terminology listing of descriptive
terms for reporting medical services
(1). The list is intended to be a guide for
comprehensive O&P providers and is
only relevant to the clinical services described. Given the need for consistency
and accuracy, it is hoped these descriptions will provide a much needed
source of clarification for today's increasingly complex O&P services.
The categories are summarized in
Table B
in accordance with the duration of the evaluation and assessment
procedure, the minimum extent of documentation required for O&P service
to be provided and the necessary interaction with the referring physician or
referral source.
Conclusion
The previous principles and visit categories also may be applied to follow-up
care and treatment visits, which are described as "all" visits occurring after the
initial clinical evaluation and assessment of the patient. Subsequent diagnostic evaluations by O&P practitioners may involve monitoring general or
postoperative edema in preparation for
planning an impression procedure to
proceed with primary care; diagnostic
muscle and/or EMG assessment procedures; fitting assessments due to physiological or pathomechanical changes; fitting adjustments and/or modifications
to an orthosis or prosthesis; and functional assessments, care, and maintenance of an orthosis or prosthesis.
Equally important is the relationship
of the principle elements of the clinical
evaluation and assessment process to
the development of a well-structured
consultation report as outlined in Table
A
. The previously described elements
provide the format for a well-structured and concise consultation report,
which is increasingly becoming a necessity in today's managed-care environment. The elements also provide an
outline for consistent and appropriate
documentation in a well-structured
quality assurance program.
This article attempts to define the
principle elements of an appropriate
O&P clinical evaluation and assessment for practitioners who have not
encountered formal training or informational material about the subject.
Additionally, given the need for consistency and accuracy in the evaluation
process, it is hoped the evaluation and
assessment visit categories will provide
a much needed enhancement and clarification for defining the increasing
complexities of O&P services. If nothing else, this article may at least confirm
the service aspect of providing O&P
healthcare today.
JOHN N. BILLOCK, CPO, is president of
the American Academy of Orthotists and
Prosthetists and executive clinical director
of Orthotics and Prosthetics Rehabilitation
Engineering Centre Inc. in Warren, Ohio.
References:
- American Medical Association. Physicians' Current Procedural Terminology.
|
