Harmony Healthcare Blog

Therapy: When is it Evaluation? When is it Treatment?

Posted by James Enos on Thu, Feb 01, 2018


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Nurse helping senior patient in exercising with resistance band in clinic.jpegLeadership involves constant communication, education and reinforcement of clinical and operational expectations.  Knowledge of state and federal regulations are the foundation for reimbursement and treatment guidelines. 

Explaining the difference between therapy evaluations and therapy treatments may seem to be unnecessary.  However, oftentimes the simplest of concepts requires communication, education and reinforcement.There is a significant difference between the two and clarification is needed not only for the therapy team, but also for the entire interdisciplinary team.  

The primary difference between therapy evaluations and therapy treatments is the Clinical Reasoning Skills of the therapist.  

Download Nursing and Therapy Skilled Documentation: Top Pillars

When Is It Evaluation?  The therapy evaluation thought process is a mental set of constant observation and interpretation of patient abilities and behaviors to develop an ever-clearer picture of the patient’s problems and necessary interventions.  

A Skilled Therapy Evaluation includes: 

  • interview with the patient, caregivers and/or the patient’s family
  • observation of functional tasks
  • assessment specific to each discipline’s scope of practice.
  • review and interpretation of the patient’s medical record
  • data collection to determine the root cause of the impairment 

When Is It Treatment?  Treatment consists of the implementation, technique, approach and/or method to affect change once the deficit has been identified. When we know the baseline and begin intervention, development and execution we are treating. 

A Skilled Treatment consists but not limited to the following: 

  • therapeutic exercise
  • introduction of memory aides and strategies
  • pain management techniques
  • tactile and verbal cueing to achieve a result
  • gait training
  • iADL and ADL task
  • education and/or compensatory strategy training 

The transition from evaluation to treatment is patient specific and is based on the judgment of the clinician. When the clinicians thought process turns into actions to assist the patient in performing or learning a functional or cognitive task, that is the point of treatment. It is feasible that the Evaluation and Treatment occur at the same time.  For example, when a Therapist is performing an evaluation, a situation arises that is a treatment….like the utilization of a positioning device to prevent injury or contracture.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have. You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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Topics: Therapy Evaluation

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