PTA responsibilities, research, and ADA

Professional responsibilities in physical therapy

Ethical principles

• Core principles:
  • Autonomy: Respect the patient’s right to make their own decisions.
  • Beneficence: Always act in the patient’s best interest
  • Nonmaleficence: “Do no harm” - avoid interventions that cause unnecessary injury or suffering
  • Justice: Deliver care fairly and without discrimination
  • Veracity: Be honest in all interactions with patients and colleagues

Informed consent

• Informed consent includes:
  • Explanation of diagnosis, proposed treatment, risks, and alternatives
  • Opportunity for questions
  • Voluntary agreement without coercion

HIPAA (Health Insurance Portability and Accountability Act)

Definitions

HIPAA

A federal law, passed in 1996, that establishes national standards protecting sensitive patient health information from being disclosed without a patient’s consent or knowledge.

HIPAA guidelines for PTA

• Share PHI without separate authorization only for treatment, payment, or health-care operations (e.g., discussing a patient with the referring physician or the payer), and only the minimum necessary; get the patient’s written authorization for other disclosures (e.g., to an employer or attorney). Information relevant to a family member’s or friend’s involvement in care may be shared if the patient agrees or, given the chance, does not object.
• Access patient information only when directly involved in that patient’s care, following the “minimum necessary” standard for protected health information (PHI).
• Discuss patient information only with those involved in care, verify identity before sharing, and avoid discussing PHI in public areas such as elevators, hallways, or waiting rooms.
• Secure records: log off workstations when stepping away, never share login credentials, and retrieve or dispose of printed PHI promptly.
• Protect patient privacy during treatment with proper draping and positioning, and avoid discussing other patients during sessions.
• Send PHI only through approved, secure channels - never by personal text, email, or photo - and confirm the recipient before sending.

Legal considerations

• Negligence: Failure to provide standard care that results in harm
• Malpractice: Professional misconduct or lack of skill leading to injury
• Abandonment: Inappropriate discontinuation of care without proper notice or referral
  • Avoid by: Providing a transition plan, proper documentation, and clear communication
• Mandatory reporting: report suspected abuse, neglect, or fraud to the appropriate authority or supervisor, as required by state law and facility policy; unexplained bruises, pressure marks, burns, or fractures suggest abuse, and the PTA reports the suspicion without verifying it
  • Fraud examples tested on the exam: billing for services not provided, upcoding, billing aide-delivered care as skilled therapy, and documenting minutes that weren’t delivered
• Workplace conduct: comply with OSHA safety standards and facility harassment policies; report violations through proper channels

Cultural and socioeconomic factors

• Use a qualified medical interpreter, not family members, when a language barrier exists
• Use teach-back and plain language when health literacy is low
• Consider social determinants of health - transportation, cost, housing, and food access - that can affect appointment attendance and home program adherence

Laws, regulations, and accrediting bodies

• ADA (Americans with Disabilities Act): civil-rights law banning disability discrimination in employment and public accommodations; requires reasonable accommodation
• IDEA (Individuals with Disabilities Education Act): guarantees free appropriate public education; school-based PT is a related service under an IEP (ages 3-21) or an IFSP (birth-3)
• Patient bill of rights: right to information, to refuse treatment, to privacy, and to respectful care
• State practice act and licensing board: define PTA scope of practice and supervision requirements
• Joint Commission: accredits hospitals and health systems
• CARF: accredits rehabilitation programs
• CMS (Centers for Medicare and Medicaid Services): sets Medicare/Medicaid rules, including documentation and supervision requirements for billing
• EMTALA: hospitals with emergency services must provide a screening exam and stabilizing treatment for emergency conditions regardless of ability to pay

Example: Reporting scenario

On a home visit, a PTA sees unexplained bruising that doesn’t match the reported injury, and learns a colleague bills one-on-one therapy for visits an aide provided.

Answer: Don’t investigate alone. Document the objective findings, report the suspected abuse to the supervising PT and/or adult protective services as state law requires, and report the billing fraud through the facility’s compliance channels - both reports are mandatory.

Supervision guidelines

• PTA supervision:
  • PTA must follow the PT’s plan of care
  • PT must be available for consultation
  • Supervision laws vary by state; direct or general supervision may be required
• PT aide supervision:
  • Aides may perform non-skilled tasks under direct supervision
• Roles on the care team:
  • PT: examination, evaluation, diagnosis, prognosis, plan of care, re-evaluation, discharge
  • PTA: carries out interventions within the PT’s plan of care and collects data
  • OT: ADLs and upper-extremity function
  • SLP: speech, language, and swallowing
  • Aide/support staff: non-skilled tasks (e.g., setup and cleaning)
  • Nurse: monitors vital signs, administers medication
  • Physician: medical diagnosis and overall treatment plan
  • Case manager: coordinates discharge planning and resources
  • Social worker: psychosocial support and community resources

Watch-out: A PTA carries out the PT’s established plan of care and collects data - the PTA does not perform the initial evaluation or re-evaluation, and does not set or change goals or the plan of care. If a patient’s status changes, the PTA recognizes it and communicates it to the supervising PT.

Delegation and communication

• Effective delegation:
  • Assign tasks based on the individual’s qualifications and legal scope
  • Ensure understanding of expectations
  • Monitor and provide feedback
• Professional communication:
  • Use SBAR (Situation, Background, Assessment, Recommendation) for concise clinical updates
  • If a patient shows an adverse response during a delegated intervention (e.g., abnormal vital-sign response, new chest pain, or dyspnea), stop the activity and report it to the supervising PT immediately

Research concepts and evidence-based practice

Levels of evidence

• Level 1a: systematic review / meta-analysis of randomized controlled trials (RCTs)
• Level 1b: individual randomized controlled trials
• Level 2: cohort studies (prospective)
• Level 3: case-control studies (retrospective)
• Level 4: case series or low-quality cohort and case-control studies
• Level 5: expert opinion without critical appraisal

Finding the evidence

• Peer-reviewed journal articles: searched in PubMed or PEDro (a physical therapy database)
• Scientific (conference) proceedings: abstracts and posters with early, often preliminary results, not fully peer reviewed
• Clinical practice guidelines (e.g., APTA’s CPGs): recommendations based on a systematic review of the evidence
• Clinical prediction rules: combine a few history and exam findings to guide diagnosis, prognosis, or treatment choice (e.g., Wells criteria for DVT, Ottawa knee rules)

Study types and research designs

• Quantitative research: uses numerical data to measure and test theories
  • Descriptive: case reports, case series
  • Analytical:
    • Observational: cohort (prospective), case-control (retrospective), cross-sectional
    • Experimental: Randomized controlled trials (RCTs), the gold standard
• Qualitative research: non-numerical data on experiences and meanings, collected through interviews, focus groups, and observation, then analyzed thematically
• Data-collection methods (used in both types): surveys and questionnaires capture self-reported opinions but invite recall and social-desirability bias; direct observation records behavior directly, though people may change it when watched (Hawthorne effect)
• Random sampling from the population is the basic requirement for generalizing a study’s results
• Sampling error is the difference between a sample’s result and the population value, with variability measured by the standard error; measurement error (e.g., misclassification) can bias results, so instruments should be valid and reliable

Statistical concepts

P-values

• A p-value < 0.05 typically indicates a statistically significant difference
• A lower p-value suggests stronger evidence against the null hypothesis
• A p-value shows whether an effect is present, not how large it is; also judge the effect size and confidence interval

Confidence intervals (CI)

• A 95% CI is a range that, across repeated sampling, would contain the true value about 95% of the time
• Narrow CI = more precise results; wide CI = more variability
• A significant result in a large study may not be clinically important; statistical significance is not clinical importance

Reliability and validity

• Reliability: consistency of a test
  • Test-retest: the same test gives consistent results over time when the trait hasn’t changed
  • Intrarater: the same clinician gets consistent results across repeated measurements
  • Interrater: different clinicians get consistent results measuring the same patient
• Validity: accuracy - does the tool measure what it’s intended to?
  • Content validity: the items adequately cover the domain being measured
  • Construct validity: the tool measures the theoretical concept it claims to measure
  • Criterion validity: results agree with a gold-standard measure, either at the same time (concurrent) or in predicting a future outcome (predictive)

Sensitivity, specificity, predictive values

• Sensitivity: true positive rate; a highly sensitive test with a negative result rules out a condition (SnNOUT)
• Specificity: true negative rate; a highly specific test with a positive result rules in a condition (SpPIN)
• False negative: test result indicates a condition is absent when it is actually present
• False positive: test result indicates a condition is present when it is actually absent
• Positive predictive value (PPV): likelihood that a positive test result is correct
• Negative predictive value (NPV): likelihood that a negative test result is correct

Example: Calculating sensitivity and specificity

A special test is performed on 100 patients. Of the 60 patients who truly have the condition, the test is positive for 48 (true positives) and negative for 12 (false negatives). Of the 40 patients who don’t have the condition, the test is negative for 32 (true negatives) and positive for 8 (false positives).

	Condition present	Condition absent
Test positive	48 (TP)	8 (FP)
Test negative	12 (FN)	32 (TN)

• Sensitivity = TP / (TP + FN) = 48 / 60 = 0.80, or 80%
• Specificity = TN / (TN + FP) = 32 / 40 = 0.80, or 80%
• PPV = TP / (TP + FP) = 48 / 56 ≈ 0.86, or 86%
• NPV = TN / (TN + FN) = 32 / 44 ≈ 0.73, or 73%

Answer: Sensitivity 80%, specificity 80%, PPV ≈86%, NPV ≈73%

Measurement scales

• Nominal: Categories without order (e.g., gender, blood type)
• Ordinal: Ordered categories (e.g., MMT grades, pain scale)
• Interval: Equal intervals, no true zero (e.g., temperature)
• Ratio: Equal intervals with a true zero (e.g., height, weight, time)

Match test to data: paired t-test (difference between two measurements from the same group), ANOVA (difference between group means), chi-square (association of two categorical variables), Pearson correlation (association of two continuous variables).

Hypothesis testing and data interpretation

• Null hypothesis (H₀): No difference or relationship
  • No significant difference is only an absence of evidence of a difference; it does not prove the treatments are equivalent
• Alternative hypothesis (H₁): A difference or relationship exists
• Power: probability of rejecting a false null hypothesis (1 minus the Type II error rate); small samples and small effect sizes reduce it

Anchor for Type I vs Type II: picture a courtroom where the null hypothesis is “innocent.” A Type I error (α) convicts an innocent person - you reject a true null and claim a difference that isn’t really there (a false positive). A Type II error (β) lets a guilty person go free - you fail to reject a false null and miss a difference that really is there (a false negative).

Healthcare system and practice management

Reimbursement models

• Medicare: Federal program for individuals 65 and older or with certain disabilities
• Medicaid: Jointly federal-state funded, state-administered program for low-income individuals
• HMO (health maintenance organization): Requires PCP referral, lower cost
• PPO (preferred provider organization): More flexibility, higher premiums

Documentation standards

• SOAP notes: Subjective, Objective, Assessment, Plan
• ICD-10: Diagnosis coding
• CPT codes: Billing for procedures
• Documentation must be timely, accurate, legible, and support skilled care
• Electronic medical record (EMR): document at or near the time of the visit; correct with a dated addendum that keeps the original visible; write each note for that visit (cloned notes lack patient-specific detail)

Risk management and quality assurance

• Incident (occurrence) report: complete one per facility policy for any unusual event (a fall, a burn, an equipment failure, a near miss), stating only objective facts. Chart the event and the patient’s condition, but never mention the incident report in the medical record.
• Peer chart review (chart audit): a quality-assurance check of sampled notes against documentation standards

Continuum of care

• Acute care: Immediate medical care (hospital)
• Subacute care: Less intensive than acute, but still requires skilled therapy
• Outpatient rehab: For patients well enough to live at home
• Home health: Therapy provided in the patient’s home

Discharge planning and case management

• Begins early in care and weighs the patient’s home environment, support system, functional status, need for durable medical equipment (DME), and follow-up services

Environmental accessibility and the ADA

Americans with Disabilities Act (ADA) guidelines

• ADA standards apply to public buildings and workplaces; clinicians use them as the benchmark when recommending home modifications.
• Doorway width: Minimum 32 inches wide
• Hallway width: Minimum 36 inches wide
• Ramp slope: Maximum 1:12 (for every inch of rise, at least 12 inches of run)
• Ramp handrails: both sides when rise is greater than 6 inches
• Thresholds: ≤ ½ inch for easy wheelchair navigation
• Bathroom access:
  • Grab bars: 33-36 inches high
  • Toilet seat height: 17-19 inches

Wheelchair accessibility features

• Turning space: a 60-inch-diameter circle (or a T-shaped turning space) minimum
• Clear floor space: 30 x 48 inches minimum
• Reach range:
  • High: Max 48 inches
  • Low: Min 15 inches
• Accessible pathway: Free from obstacles, level, non-slip surface