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.

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