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13 Cards in this Set
- Front
- Back
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Health condition (ICF)
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acute or chronic disease, disorder, injury, trauma
may include: pregnancy, aging, stress, fitness, congenital anomalies, genetics |
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relevance of taking a hx
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provides foundation for referral to PT
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ICF framework
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Health conditions leads to
Body structure & fx (impairments) ↔ Activity limitations ↔ Participation restrictions links between these 3 items are influenced by contextual factors that are environmental / personal |
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Categories to document health condition & referral reason
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pt info & demographics
current condition past medical hx meds other, if pertinent |
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pt info & demographics
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first items in documentation
name, DOB, eval date, sex pertinent demographic info |
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current condition
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referral reason
why pt sought PT current & prior therapeutic interventions mechanisms of injury or disease - underlying disease process, location, duration any previous occurrences of current condition |
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past medical hx (PMH)
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surgeries, dx, pre-existing conditions
date or time course of medical condition / surgery if PMH is in another part of the chart, then document that PMH was confirmed by pt & reference location of PMH |
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Meds
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'scrip, OTC
name, dosage, reason supplements, if pertinent |
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Other
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developmental hx
family hx |
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Obtaining health condition info
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direct from physician (chart or communication)
direct from pt (less reliable) obtained through 3d party document source of info |
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diagnoses & direct access
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medical dx may not be available
may require referral to physician or other practitioner |
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prevention & wellness
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primary
no presenting dx or illness secondary decr duration / severity of illness / disorder & sequelae tertiary decr degree of disability, promote rehab, restore fx |
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elements of a health condition
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underlying disease process
incl type of pathology results of dx tests any referring info location specific tissues that are involved / affected time course duration of condition, date of injury / surgery / dx |
