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Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment i
CPT4 code
Name of the Procedure:
Re-evaluation of Physical Therapy Established Plan of Care
Summary
This procedure involves re-assessing a patient's current physical therapy plan, including a thorough examination, review of medical history, and use of standardized tests and measures. The goal is to revise the plan of care based on the standardized patient assessment to ensure optimal recovery and progress.
Purpose
- Addresses: Updating and optimizing physical therapy for improved patient outcomes.
- Goals: To ensure the physical therapy regimen is effectively facilitating the patient's recovery and adapting to any changes in their condition.
Indications
- Symptoms/Conditions: Slowed or stagnated progress in current therapy, new symptoms, or changes in condition.
- Patient Criteria: All patients undergoing physical therapy who require a progress check or adjustment in their therapy regimen.
Preparation
- Pre-procedure Instructions: No specific fasting or medication adjustments typically required.
- Pre-assessments: Review of recent medical history and any diagnostic imaging or tests relevant to the patient's condition.
Procedure Description
- Examination: Comprehensive review of patient's medical history.
- Use of standardized tests and measures to evaluate the patient's current status.
- Discussion with the patient about their progress, symptoms, and any concerns.
- Development of a revised plan of care using data from the standardized patient assessment. Tools/Technology: Standardized testing equipment (e.g., goniometers, dynamometers), patient records. Anesthesia/Sedation: Not applicable.
Duration
Typically 30-60 minutes.
Setting
Outpatient clinic.
Personnel
- Primary: Licensed physical therapist.
- Support: Possibly a physical therapy assistant or aide.
Risks and Complications
- Common Risks: Minimal; includes temporary discomfort during assessment.
- Rare Complications: Uncommon but may include exacerbation of symptoms due to examination.
Benefits
- Expected Benefits: Optimized recovery, better-targeted therapy strategies, and enhanced progress.
- Realization Timeline: Immediate adjustments can lead to more effective therapy and quicker improvement.
Recovery
- Post-Procedure Care: Normal activities can usually be resumed immediately.
- Recovery Time: Not applicable as this is a non-invasive assessment.
- Follow-Up: Scheduled follow-up appointments as per revised care plan.
Alternatives
- Other Options: Continuation with the current plan without re-evaluation, another physical therapist's second opinion, or alternative therapies (e.g., chiropractic care, massage therapy).
- Pros and Cons: Alternative options may not provide as targeted or effective adjustments as a re-evaluation would.
Patient Experience
- During Procedure: Patients may experience slight discomfort from physical assessments.
- After Procedure: Should feel minimal to no discomfort; may feel encouraged by revised plan.
- Pain Management: None typically required; measures provided if any discomfort arises.