Guide to Physical Therapist Practice: Revisions.

In July 1999, APTA revised the Guide to Physical Therapist Practice (Guide) to reflect actions taken by APTA's House of Delegates in June at Physical Therapy '99 in Washington, DC. The actions primarily involved policy regarding the physical therapist assistant and the physical therapy aide.

The July 1999 revisions, including the addition of two ICD-9-CM codes, are listed on pages 1079 through 1081. (These revisions also were listed in the September issue of PT--Magazine of Physical Therapy.) This is the final set of revisions to the first edition of the Guide. The second edition of the Guide is scheduled for release at the end of the year 2000 and will contain Parts Three and Four (to include the "minimum data set" of information to be collected on all patients managed by physical therapists, in addition to annotated lists of specific tests and measures used in examination and functional outcome measures).

For more information about the Guide, contact APTA's Department of Practice at 800/999-2782, ext 3176, or write to GUIDE, Division of Practice and Research, APTA, 1111 North Fairfax Street, Alexandria, VA 22314-1488. The July 1999 revised Guide (both in print and on CD) is available through APTA's Service Center, ext 3395, or via e-mail at [e-mail]. The complete list of revisions made since 1997 is accessible online from APTA's Web site, http://www.apta.org.

The Physical Therapist Assistant and the Physical Therapy Aide

Originally, the Guide stated that "physical therapy [should] be provided only by, or under the direction and supervision of, a physical therapist." Based on the amendment to APTA's "Position on Physical Therapy Intervention" (RC 5), the Guide now specifies (Guide pages vii, viii, 1-1, 2-1, 3-1):

   Physical therapists are the only professionals and physical therapist
   assistants--under the direction and supervision of the physical
   therapist--are the only paraprofessionals who provide physical therapy
   interventions. APTA therefore recommends that federal and state government
   agencies and other third-party payers require physical therapy to be
   provided only by (1) physical therapists or (2) physical therapist
   assistants under the direction and supervision of a physical therapist.
   Examination, evaluation, diagnosis, and prognosis are physical therapy--and
   should be represented and reimbursed as physical therapy--only when they
   are performed by a physical therapist. Intervention is physical
   therapy--and should be represented and reimbursed as physical therapy--only
   when performed by a physical therapist or under the direction and
   supervision of a physical therapist.

The definitions for physical therapist assistant and physical therapy aide have been revised (Guide page 1-10):

   The physical therapist assistant is a technically educated health care
   provider who assists the physical therapist in the provision of physical
   therapy. The physical therapist assistant, under the direction and
   supervision of the physical therapist, is the only paraprofessional who
   provides physical therapy interventions. The physical therapist assistant
   is a graduate of a physical therapist assistant associate degree program
   accredited by the Commission on Accreditation in Physical Therapy Education
   (CAPTE).

   The physical therapist of record is directly responsible for the actions of
   the physical therapist assistant. The physical therapist assistant may
   perform specific components of physical therapy interventions, where
   allowable by law or regulations, that have been selected by the supervising
   physical therapist. The ability of the physical therapist assistant to
   perform the selected interventions should be assessed on an ongoing basis
   by the supervising physical therapist. The physical therapist assistant may
   modify an intervention only in accordance with changes in patient/client
   status and within the scope of the plan of care that has been established
   by the physical therapist....

   Aides are any support personnel who may be involved in the provision of
   physical therapist-directed support services. The physical therapy aide is
   a nonlicensed worker who is specifically trained under the direction and
   supervision of a physical therapist.

   Physical therapist-directed support services are limited to those
   tasks--which may include methods and techniques--that do not require
   clinical decision making by the physical therapist or clinical problem
   solving by the physical therapist assistant. The determination of what
   tasks are appropriately directed to the aide must be made by the physical
   therapist or, where allowable by law or regulations, the physical therapist
   assistant. To make this determination, the physical therapist or physical
   therapist assistant must have direct contact with the patient/client during
   each session. The aide may function only with continuous on-site
   supervision by the physical therapist or, when allowable by law or
   regulations, the physical therapist assistant.

Responsibilities of the Physical Therapist

Consistent with RC 4A, which amended and retitled "Direction, Delegation, and Supervision of the Physical Therapist Assistant" (HOD 06-96-30-42), the Guide now describes the responsibilities borne solely by the physical therapist as follows (Guide page 1-11):

* Interpretation of referrals when available

* Initial examination, evaluation, problem identification, diagnosis, and prognosis

* Development or modification of a plan of care that is based on the initial examination or the reexamination and that includes physical therapy anticipated goals and expected outcomes

* Administration of intervention and, as appropriate, Determination of (1) tasks that require when the expertise and decision-making capacity capability of the physical therapist requires the physical therapist to personally render physical therapy interventions and (2) tasks that may be delegated when it may be appropriate to utilize the physical therapist assistant. Prior to delegating any procedure, the physical therapist should determine that the consequence of the procedure are predictable, the situation is stable, and the basic indicators are not ambiguous and do not require ongoing observation by the physical therapist. A physical therapist determines the most appropriate utilization of the physical therapist assistant that will ensure the delivery of service that is safe, effective, and efficient.

* Delegation of the tasks to be rendered by the physical therapist or other support personnel, including, but not limited to, specific treatments, precautions, special problems, and contraindicated procedures

* Timely review of treatment documentation Reexamination of the patient/client and in light of the anticipated goals and expected outcomes, and revision of the plan of care when indicated

* Establishment of the discharge plan and documentation of discharge summary/status

* Oversight of all documentation for services rendered to each patient

Episode of Care

The following clarifications have been made to the definition of episode of care, which was added to "What Are Physical Therapists, and What Do They Do?" (Guide pages 1-8, 1-9):

   An episode of physical therapy care consists of all physical therapy
   services that are (1) provided by a physical therapist or under the
   direction and supervision of a physical therapist, (2) provided in an
   unbroken sequence, and (3) related to the physical therapy interventions
   for a given condition or problem or related to a request from the
   patient/client, family, or other health care provider. The episode of care
   may include transfers between sites within or across settings or
   reclassification of the patient/client diagnostic group from one preferred
   practice pattern to another. Reclassification may alter the expected range
   of number of visits and therefore may shorten or lengthen the episode of
   care. If reclassification involves a condition, problem, or request that is
   not related to the initial episode of care, a new episode of care may be
   initiated....

   A single episode of care should not be confused with multiple episodes of
   care that may be required by certain individuals in particular
   patient/client diagnostic groups. For these patients/clients, periodic
   follow-up is needed over a lifetime to ensure optimal function and safety
   and effective adaptation following changes in physical status, caregivers,
   the environment, or task demands.

"Movement and Health"

At the June House, the "Philosophical Statement on Physical Therapy" (HOD 06-83-03-05) was retitled to "Position on Physical Therapy as a Health Profession" and amended. As a result of the changes, the Introduction of the Guide (page vii) now states that physical therapists help

   ...Restore, maintain, and promote overall fitness and optimal quality of
   life as related to movement and health.

ICD-9 Codes

Neuromuscular Practice Patterns

Pattern 5A: Impaired Motor Function and Sensory Integrity Associated With Congenital or Acquired Disorders of the Central Nervous System in Infancy, Childhood, and Adolescence 

   Page 5A-2

   Two ICD-9-CM codes have been added

   758 Chromosomal anomalies Includes: syndromes associated with anomalies in
   the number and form of chromosomes

   759 Other and unspecified congenital anomalies

Standards of Practice for Physical Therapy and the Criteria

APTA's Standards of Practice for Physical Therapy and the Criteria (Appendix 2 of the Guide) also has been revised to reflect the June House actions. Most of the revisions have been made under "Provision of Services" (III A-G). That section is as follows:

III. Provision of Services

A. Informed Consent

The physical therapist has sole responsibility for providing information to the patient and for obtaining informed consent in accordance with jurisdictional law before initiating intervention.

The information provided to patients:

* Clearly describes the proposed intervention.

* Delineates material (decisional) risks associated with the proposed intervention.

* Identifies expected benefits of the proposed intervention.

* Compares the benefits and risks possible both with and without the proposed intervention.

* Explains reasonable alternatives to the proposed intervention.

Informed consent:

* Requires consent of a competent adult.

* Requires consent of a parent/legal guardian as the surrogate decision maker when the adult patient is not competent or when the patient is a minor.

* Requires the patient or legal guardian to acknowledge understanding of the intervention and to give consent before intervention is initiated.

B. Initial Examination/Evaluation/ Diagnosis/Prognosis

The physical therapist performs an initial examination and evaluation to establish a diagnosis and prognosis prior to intervention.

The physical therapist examination:

* Identifies the physical therapy needs of the patient/client.

* Incorporates appropriate tests and measures to facilitate outcome measurement.

* Produces data that are sufficient to allow evaluation, diagnosis, prognosis, and the establishment of a plan of care.

* May result in recommendations for additional services to meet the needs of the patient/client.

C. Plan of Care

The physical therapist establishes a plan of care for the patient/client based on the examination, evaluation, diagnosis, prognosis, anticipated goals, and expected outcomes of the planned interventions for identified impairments, functional limitations, and disabilities.

The physical therapist involves the patient/client and appropriate others in the planning, implementation, and assessment of the intervention program.

The physical therapist, in consultation with appropriate disciplines, plans for discharge of the patient/ client, taking into consideration achievement of anticipated goals and expected outcomes, and provides for appropriate follow-up or referral.

The plan of care:

* Identifies realistic long-term and short-term goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others.

* Describes the proposed intervention, including frequency and duration.

D. Intervention

The physical therapist provides, or directs and supervises, the physical therapy intervention consistent with the results of the examination, evaluation, diagnosis, prognosis, and plan of care.

The intervention:

* Is provided under the ongoing direct care of or under the direction and supervision of the physical therapist.

* Is provided in such a way that responsibilities are commensurate with the qualifications and the legal limitations of the physical therapist assistant and of the support personnel who may be involved in the provision of physical therapist-directed support services.

* Is altered in accordance with changes in response or status.

* Is provided at a level that is consistent with current physical therapy practice.

* Is interdisciplinary when necessary to meet the nee& of the patient/client.

E. Reexamination

The physical therapist reexamines the patient/client as necessary during an episode of care to evaluate progress or change in patient/client status and modifies the plan of care accordingly or discontinues physical therapy services.

The physical therapist reexamination:

* Identifies ongoing patient/client needs.

* May result in recommendations for additional services, discharge, or discontinuation of physical therapy services.

F. Discharge/Discontinuation of Intervention

The physical therapist discharges the patient/client from physical therapy services when the anticipated goals or expected outcomes for the patient/client have been achieved.

The physical therapist discontinues intervention when the patient/ client is unable to continue to progress toward goals or when the physical therapist determines that the patient/client will no longer benefit from physical therapy.

Discharge:

* Occurs at the the end of an episode of care and is the end of physical therapy services that have been provided during that episode.

Discontinuation:

* Also occurs when the patient/client, caregiver, or legal guardian declines to continue intervention.

G. Communication/Coordination/ Documentation

The physical therapist communicates, coordinates, and documents all aspects of patient/client management, including the results of the initial examination and evaluation, diagnosis, prognosis, plan of care, interventions, response to interventions, changes in patient/client status relative to the interventions, reexamination, and discharge/ discontinuation of intervention.

Physical therapist documentation:

* Is dated and appropriately authenticated by the physical therapist who performed the examination and established the plan of care.

* Is dated and appropriately authenticated by the physical therapist who performed the intervention or, when allowable by law or regulations, by the physical therapist assistant who performed specific components of the intervention as selected by the supervising physical therapist.

* Is dated and appropriately authenticated by the physical therapist who performed the reexamination, and includes modifications to the plan of care.

* Is dated and appropriately authenticated by the physical therapist who performed the discharge, and includes the status of the patient/client and the goals and outcomes achieved.

* Includes, when a patient/client is discharged prior to achievement of goals and outcomes, the status of the patient/client and the rationale for discontinuation.3