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INTRODUCTION

The following section presents portions of a pilot outcome study conducted by George Gabriel, PT, DPT, which helps to illustrate the steps of outcome measurement described in prior chapters. This selection is presented as one person’s exploration into documentation patterns and is not meant to represent the only “right answers” that result from conducting an outcome study. Additionally, this study was conducted as a course project during a single academic semester, so the number of charts and the amount of literature reviewed are artificially limited by the constraints of time. When conducting a study in the clinical setting, the investigating clinician will need to consider a larger sample size and a more thorough review of the literature.

Clarifying comments and alternate approaches to selected parts of the study are presented in boxes. These comments may expand on what is presented in the text or serve as a reminder of points to consider. In all cases, if you need more explanation, refer to the respective chapter(s) in the text.

The sample illustrates the same question that is suggested as a starting point for clinicians who are just starting outcome research based on their own clinical data. Keep in mind that the results and conclusions of every study will be different based on the diagnosis of interest, the clinicians whose records are reviewed, the type and demands of the setting in which the clinicians are documenting, and the literature reviewed by the investigating clinician.

A SAMPLE STUDY OF DOCUMENTATION PATTERNS

George L. Gabriel, PT, DPT, with book adaptations and comments by Sandra L. Kaplan, PT, PhD

QUESTION

For patients with a diagnosis of low back pain managed by this physical therapist in an urban hospital, outpatient setting, who have impairment and functional goals established during the initial visit, what is the frequency and measurability of each category of goal?

In PICO/PIO Format

  • P: For patients with a diagnosis of low back pain managed by this physical therapist in an urban hospital, outpatient setting,

  • I: who have impairment and functional goals established during the initial visit,

  • O: what is the frequency of each type of goal?

  • O: what is the measurability of each type of goal?

Comment

In this case, the question is phrased as a PIO question, with the intent to describe the results without a comparison component. The question could also be phrased as follows if the clinician were interested in comparing the frequencies:

  • P: For patients with a diagnosis of low back pain managed by this physical therapist in an urban hospital, outpatient setting,

  • I: who have impairment goals,

  • C: and functional goals established during the initial visit,

  • O: what is the difference in frequencies of each type of goal?

  • O: what is the difference in measurability of ...

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