Direct Access, Cauda Equina Red Flags, and Emergency Referral
Mark, 58, walks into a New Hampshire clinic without a referral. He has had low back pain for three weeks after moving furniture. He reports new numbness in both feet and buttocks, difficulty starting urination, and a history of prostate cancer treated five years ago. He denies fever but says his pain is worse at night. He asks the PT to 'just fix it' and says his primary care physician is on vacation for two weeks. The PT's examination finds decreased perineal sensation, bilateral ankle dorsiflexion weakness, and a distended bladder palpable above the pubis. Mark has no signed physician referral and no imaging. The clinic's front desk asks whether New Hampshire's direct-access law lets the PT begin lumbar traction and exercises that day, or whether the PT must send him to the emergency department.
1. Under New Hampshire direct access, may the PT evaluate and treat Mark without a referral?
Read the worked answer
New Hampshire permits a physical therapist to examine, evaluate, and treat a patient without a physician referral, but direct access does not expand the PT's scope. Mark's saddle anesthesia, bilateral leg weakness, urinary retention, and cancer history suggest cauda equina syndrome, a medical emergency. The PT may perform a screening examination, but must not begin lumbar traction or exercise. The PT should arrange immediate emergency department evaluation and document the reason. Direct access is not authority to treat a condition that requires emergency medical diagnosis or care.
2. What referral and communication steps are required?
Read the worked answer
The PT must refer Mark emergently. Call the emergency department, give a verbal report, provide a written referral note, and tell Mark not to drive himself. Notify the primary care physician even if the office is on vacation; the emergency department can reach the covering physician. Document the red flags, the decision, who was contacted, and the instructions given to Mark. Do not wait for imaging or primary care clearance. The PT should also give Mark written instructions to return or call if symptoms worsen before he reaches the emergency department.
3. How should the PT document this direct-access encounter?
Read the worked answer
The record should state that Mark presented without a referral, that New Hampshire direct access was explained, and that the PT performed a screening examination. It should include the history, objective findings, suspected emergency, referral, and communications with the emergency department and primary care office. Record that no physical therapy intervention was provided. Use objective terms and avoid conclusory labels. This documentation protects Mark and demonstrates appropriate scope judgment.