503 - Documentation

Front 1

Disablement Model
(Nagi Model)
components?

Back 1

Pathololgy/Condition - (ICF)
Impariment - (Body Structure Function)
Functional Limitation - (Activity)
Disability - (Participation)

Front 2

Pathology / Condition

Back 2

* the medical diagnosis, ongoing pathological state.
* Can be a result of infection, trauma, imbalance, degenerative process, etc.

Front 3

Impairment

Back 3

* Changes to structures (anatomical, physio or psycho) or functions
* It both contributes to and results from illness
* ID'ed and managed by PT

Front 4

Functional Limitation

Back 4

Inability to perform a physical action, activity in an efficient, typically expected, or competent manner

Front 5

Disability

Back 5

Inability or restriction to perform tasks related to self, leisure, professional roles in sociocultural context.

Front 6

Elements of Patient Management

Back 6

1. Examination
2. Evaulation
3. Diagnosis
4. Prognosis
5. Intervention

Front 7

Elements of Patient Management
* Examination

Back 7

Data gathering of:
* History
* Systems Review
* Tests & Measures
+ Re-examination

Front 8

Elements of Patient Management
* Evaluation

Back 8

Analyzing the data gathered in examionation.
Reflects the:
* severity
* chronicity
* complexity
* stability

Front 9

Elements of Patient Management
* Diagnosis

Back 9

* Label encompassing a cluster of signs & symptoms
* Guide the PT in determining most appropriate intervention strategy
* May lead to referrals

Front 10

Elements of Patient Management
* Prognosis

Back 10

Optimal level of function goal, and time needed to achieve it
* Plan of Care
* Termination criteria

Front 11

Elements of Patient Management
* Prognosis - Plan of Care

Back 11

- Goals
- Outcomes
- Specific Interventions
- Duration / Frequency

Front 12

Elements of Patient Management
* Prognosis - Criterial for Terimation of PT

Back 12

1. Discharge - anticipated goals/outcomes reached
2. Discontinuation - Ending PT due to
a. Px decline Tx
b. Unable to progress due to medical or psychosocial complications
c. PT determines Px will no longer benefit from services

Front 13

Elements of Patient Management
* Intervention

Back 13

Interaction & procedures used to achieve goals
* Px + family education
* Direct intervention
* Coordination & communication within HC system
* Referral to other professionals & resources

Front 14

2 Type of Documentation Format

Back 14

SOAP (traditional

Guide (Patient/client management)

Front 15

3 Types of Notes

Back 15

1. Initial

2. Progress

3. Discharge