In a recent patient encounter, when asked how he was doing during follow-up, my patient told me the following: “I'm doing better but I still have some pain.” At first blush, this may indicate some improvement, but does it really? These types of ambiguous responses are a real challenge for therapists making decisions about whether their patients are improving, getting worse, or staying the same. To achieve some clarity regarding his pain, when I asked him to rate his pain for the day, he scored it at a 5 on a 0 to 10 verbal pain rating scale. This score was 1 point less than the score reported on his initial evaluation about 2 weeks ago. What do I write in the medical record? How do I decide what to write? I want to capture the truth about the patient's condition, but I'm unclear on what the truth really is given his response to my question.
Dilemmas like this one are universal in physical therapy. When patients respond to questions like “How are you doing?” the risk of ambiguity rises. For example, the patient stated he was doing pretty well but he also noted his pain persisted. Does this mean he is getting better or does this mean his problems really have not changed in any meaningful way? Ambiguous responses are not isolated to patient self-reports of symptom status. Impairment measures and performance-based measures are also prone to ambiguity and error. For example, have you ever noticed when assessing a patient's grip strength or sitting posture that your findings vary with repeated testing? This book will help you to resolve these types of unclear outcome assessments. We present clear outcome assessment and provide you with several clinically feasible approaches that will help you reduce the ambiguity inherent in all outcome measures.
Physical therapists are the recognized experts at quantifying health condition/disease consequences, setting meaningful patient-centered goals, choosing interventions to resolve patient problems, and assessing changes in outcome measures over time. This last step, using outcome measures to assess change, can appear to be deceptively simple on the surface. But as the example we posed at the beginning of the chapter illustrates, outcome assessment can be nuanced and difficult to interpret. The primary objectives of this book are to take full advantage of the outcomes literature and key conceptual frameworks to help you to (1) select outcome measures that are ideally suited to your patients' needs and (2) interpret outcome measures to optimize clinical decision making for individual patients. These objectives were driven by our understanding of and appreciation for outcome measurement. In short, our philosophical approach to outcome assessment is the following. The conscientious and judicious assessment of patients' outcomes is a complex clinical skill, much like patient assessment and treatment selection and delivery, and requires a conceptual framework and a specific body of knowledge.
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