Q: If a physical therapist
does the pre-op evaluation work-up for an ACL surgery,
the treatment plan is established before surgery,
and there is not a new referral generated for these
patients, is
it legal for a PTA to see the patient for the first
treatment post-surgery? The visit would entail reviewing
what the patient was taught preoperatively: crutch
walking, ROM, quad sets, how to apply the brace and
how to use the cooling unit.
A: WI Administrative Rule PT5.01 (d through g) addresses
the issues in this question.
5.0.1(d) requires the physical therapist to develop
written procedures related to communication, care management
and supervision appropriate to the setting. If
the PT is going to allow the PTA to provide immediate
post surgical care, it is essential that written policies
are in place to describe the PT and PTA’s role,
method of communicating in the event of a change in the
patient’s condition as well as care protocols
for this type of patient.
5.01(e) requires the PT to provide the initial patient
examination, evaluation and interpretation of referrals. If
the PTA’s activity is an extension of the pre-operative
referral – and the surgeon does not write separate
post surgical referral for PT services, then the PTA
would not be prohibited from performing the activity. However,
if the PT service is initiated on the basis of a new
referral, then the PT must be available to interpret
the referral and conduct the initial evaluation post
surgically.
5.01(f) requires the PT to develop and revise as appropriate,
the written patient treatment plan and program. If
the treatment plan and program are protocol driven and
the patient’s post-op condition is as expected
and planned, then for practical purposes, the PT’s
involvement at the first post-operative visit may not
be necessary to safely care for this patient.
5.01(g) requires that the PT delegate appropriate portions
of the treatment plan and program to the PTA consistent
with the PTA’s education, training and experience.
The bottom line is that if this
activity is the result of a new referral for PT services,
the PTA cannot legally initiate the post-op visit. The PT must initiate
the care per rule(s). Even if the care is the
extension of PT services without a new referral, if
the PTA does not have the education and training required
to deal with the patient problems that may present
immediately post surgery and/or if the PT has not prepared
an adequate PT plan for post-surgical care and/or if
written policies and protocols have not been developed
(or the supervising PT and treating PTA have not been
educated in these procedures and protocols), then the
scenario above would not be consistent with current
legal requirements.
Q: I have a question regarding
a practice that is starting to be seen more and more
in the homecare environment and would like some feedback
from the association.
The practice has to do with a new device that is similar
in nature to a blood glucose glucometer only this device
is for PT/INR blood levels. Some homecare PT's
are apparently using these devices for in home Protime/INR
levels and then inform the MD, usually the orthopaedic
doctor after joint arthroplasties, instead of having
a traditional blood draw performed by a local lab. We
are interested in possibly offering this service as well
but wanted to double check with the association as to
our practice act. From the GUIDE TO PHYSCIAL THERAPY
2ND EDITION, I did not see any specific phrasing that
would relate to this, or in the Wisconsin Physical Therapy
Practice Act. Therefore, I am writing for advice
on this subject. My assumption, which is just that,
is that if we have an order to get protime/INR and the
patient self injects the "pen" and blood strip
that we could transfer the information to the MD for
medication parameters. This would be non-invasive
and related to lab results which we already monitor and
thus fall under our practice act. Any advice as
to this practice would be greatly appreciated.
A:
First, you have taken the appropriate first steps by reviewing documents that may provide the answer. You will not find anything specific in the WI PT Practice act that addresses your question because phlebotomy type procedures are not included in the scope of physical therapy. However, Legal Counsel for the PTACB reviewed this question with the PTACB in 2005 and prepared this written response.
“The Board (PTACB) determined that the performance of a prothrombin time test using a portable “ProTime meter” is not considered within the scope of practice for physical therapists. However, the Board agreed that it would not be a violation of the physical therapy practice act to do a finger stick on a patient consistent with the physician’s order provided the physical therapist has been properly trained, is competent to perform the test, and makes it clear to the patient that this procedure is not physical therapy. Obviously, a physical therapist would not be able to bill for his or her time for the test administration or for relaying the test results. You may also wish to consult with other allied health professional boards to determine whether such practices are considered with their laws.”
Q: Can a radiological tech
perform Ultrasound (1MHz/3.0-3.3MHz) treatment under
the supervision/request of a MD/DO? There is no PT on
site.
A: An MD or DO under WI Statutes is considered an "unlimited
licensed practitioner" and has authority to
train whom ever he/she chooses to deliver care that
is "complementary" to the physician's services. In
other words, yes, it is legal under WI law. The
physician could utilize a non-licensed individual in
this capacity. The physician would be responsible
to provided appropriate education, training for the
individual expected to deliver this type of care under
the supervision of the physician.
Q: Can a PT in Wisconsin
order a bone scan, CT, MRI, Radiograph? I understand
it will be interpreted by a MD/DO. I have always
contacted a MD and asked them to order it, but I
have been told by a couple that I should just order
what I want when I think it is necessary.
A: Under WI law, a PT may refer for imaging.* Physical
Therapists may use the knowledge gained from imaging
procedures to develop a care plan which may or may
not include referrals for further medical care.
A PT may not perform imaging with x-ray.
Other notes: The physician who reads the imaging (usually
a radiologist) has a responsibility to make sure that abnormal
findings are communicated to appropriate practitioners. If
the patient does not have a primary care physician, the
radiologist may have concerns about who/how to refer
on for "medical care". A referral
back to the PT for care of a tumor, for example, would
not be reasonable. This is a practical matter
that physicians often struggle with. The radiologist
may also have concerns about "who is going to share
an interpretation with the patient". Any
PT referring for imaging should prepare him/herself
to refer the patient on to an appropriate practitioner
if the results call for treatment outside of the PT
scope of practice.
Some health care organization's medical staff by-laws
and/or institutional policy may prohibit their radiology
department from completing a test referred by a PT.
Q: This question concerns a PT who will be on work restrictions
following a procedure.
Can a PT direct a PTA during an evaluation of an inpatient
if the PT cannot perform all of the physical tasks associated
with performing the evaluation? The PT would be present
during the entire evaluation, which typically consists
of assessing range of motion, strength, and functional
mobility.
A: Note that the following response
is not based on precedent or an opinion from the PTACB. Sections
of Administrative Rule PT 5 are germane.
- The PT is always responsible to perform the evaluation.
- The PT is always responsible to assure that the
PTA is competent to perform the tasks that the PT
delegates to him/her.
That said, if the PTA has been
trained in and has the knowledge necessary to measure
and report (objective measures) such as ROM and strength,
and if the PT provides immediate patient observation
and direct one-on-one supervision and direction as
the PTA takes these measurements, and the PT takes
full responsibility for analyzing the data recorded
(including the PT's observations of the patient's response
to the PTA's manual pressure/contacts,
etc.) - then the PT has met his/her obligation with respect
to the items above. General education for PTA's
includes ROM and muscle testing and a competent PTA
should have those skills, at least for basic extremity
testing.
In this situation, the "employer" is making
an reasonable accommodation for the PT who has temporary
physical restrictions/limitations (ADA requirement to
make reasonable accommodations). The PTA is "the
PT's hands" for selected activities.
You may want to include in documentation
of the results a statement such as "ROM and strength measurements
performed by PTA under the PT's direction and immediate,
one-on-one supervision".
Q: During an educational
planning meeting at our facility the following questions
was posed. Does the WPTA
grant CEU credits for presentations that are videotaped
from a live presentation. For example, if our facility
is granted CEUs for a live program and the CEUs attached
to the program are good for a year if that same presentation
is repeated, could we videotape the original
presentation and grant CEUs if the an individual views
the videotape?
A: The WPTA has presented its
process for reviewing and granting CEUs to the PTACB. The PTACB has confirmed
that the process we use meets the spirit and letter of
Administrative Rule Chapter PT 9 (Continuing Education). The
WPTA has determined that viewing a video taped presentation
is not satisfactory for the granting of CEUs. It
lacks the interactive quality that a live, audio, or
interactive on-line or self-study course provides.
Q: If an inpatient requires the assistance of two people
to work on transfer training and the time spent is 15
minutes or less can the patient be charged 2 units of
transfer training?
A: No. CPT codes and billing
rules do not factor in the number of persons required
to complete a treatment activity.
Q: Are aides allowed to perform
any direct patient care such as perform modalites or
supervise exercise programs? For
example, there is an exercise group in the inpatient
orthopedic satellite. There is a therapist conducting
the group along with the aide. Can the aide physically
assist a patient with their exercises? If the
therapist leaves the room to walk a patient back to
their room can the aide continue to exercise with that
patient?
A: Aides (unlicensed personnel)
are allowed to perform patient related tasks. In supervising an aide performing
a patient related task the therapist is responsible to “provide
direct on-premises supervision of the unlicensed personnel
at all times”. (Administrative Rule Chapter
PT 5). This rule does not specify the patient
related tasks that may or may not be performed, but
it does require the PT to determine the competence
of the aide to perform the tasks, be available at all
times for direction and supervision with the person
performing the tasks and retain full professional responsibility
for the tasks being performed.
Q: How can I be sure that the continuing education hours
that I receive from a CE course I attend will be accepted
by the PTACB as level I hours when I renew my license?
A: Administrative Rule PT 9.04
outlines the standards for approval of continuing education
programs. To
summarize the rule, the program will be accepted if
the program:
- Is an organized program that contributes to PT
professional competency;
- Includes subject matter that relates to the practice
of PT;
- Is conducted by individuals who are qualified to
teach the subject matter;
- Fulfills pre-established objectives;
- Provides proof of attendance.
Ordinarily, if a program has been approved by an agency/organization
such as the WPTA, APTA, AOTA, WOTA, AMA, ANA, etc., you
can assume that it meets the above criteria, as these
organizations follow these standard requirements for
approving programs.
