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Shifting Rehab Paradigms

Medical Screening

Published August 26, 2016 9:19 AM by Viktoriya Friedman

 

When comparing “non-claims” physicians with physicians who had suits filed against them, the average length of patient encounter time difference was only 3 minutes. The difference in length of visits had an independent effect in predicting the physicians’ claim status (1). This documented finding proves that it is not the length of visit, but the quality of the medical visit that is responsible for positive versus negative encounter. How thorough was your patient’s last doctor’s visit? How thorough was your initial physical therapy assessment of this patient? Is there a chance you overlooked acute cholecystitis and treated your patient for lower quadrant muscle strain because that was on the script from the doctor? In my professional career, I had worked with physicians who had claims against them and those who had patients’ “thank you” notes in the office. I have worked with a variety of rehabilitation professionals as well.

For PTs, just like for physicians, providing quality of care starts with a thorough medical screening process during your initial assessment. On the positive side of this is direct access, which no longer mandates a physician’s referral and allows physical therapists to evaluate and even treat (in some states). In the healthcare environment that is progressively focusing on quality of care provided, the evaluation process which includes the paramount patient interview is frequently skimmed over.

Medicare A doesn’t even reimburse (minutes are not counted towards MDS) for the therapy evaluations and Medicare B reimburses at a service-based rate, so the physical therapist must be self-motivated to spend more than 15-20 minutes since reimbursement is the same regardless of time spent with patient. 

In this case, how much time is adequate? I revert back to my initial point, if you are confident that your 15 minute evaluation covered all the bases, and you effectively communicated with and listened to your patient, it’s enough.

Medical screening is at the root of what we do. Many PTs are so used to being spoon-fed the diagnoses that they eliminate medical screening and differential diagnoses from their initial evaluation process. I had a patient come to me with a script: “PT 3 times per week for LE strengthening secondary to exacerbation of PD.” In retrospect, I am scared to think of what would happen if I didn’t complete a comprehensive evaluation. During my evaluation, findings didn’t jive with the diagnoses. I called his neurologist and asked for radiographic studies of low back but was denied. I called his PCP and asked for the same. PCP agreed and findings were positive for spinal tumor.

In another instance, a young female patient presented a script for foot pain, but was urgently referred back to orthopedics by me based on my evaluation process where she mentioned change in her regular running routine. Imaging was positive for a fifth metatarsal stress fracture and mild osteoporosis.

A healthcare provider who cannot take a good history and a patient who cannot provide on are at risk of giving and receiving compromised care. To improve the quality of care, engage in open-ended questioning, listen actively and allow for a patient-centered environment. Make your patient comfortable enough to share details.

1.       Levinson W, Roter D. Physicians’ psychological beliefs correlate with their patient communication skills. J Gen Intern Med 1995;10:375-9

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