18-26. PMM and Documentation Combined

Vocabulary flashcards covering key terms, models, processes, documentation types, and measurement concepts from the PT 7312 lecture on the Guide to Physical Therapist Practice and principles of documentation.

APTA Guide to Physical Therapist Practice

Authoritative document that describes physical therapist practice, standardizes terminology, and outlines clinical decision-making processes.

Patient/Client Management Model

Framework with six elements—Examination, Evaluation, Diagnosis, Prognosis, Intervention, Outcomes—used to guide PT care.

Examination

Systematic collection of data that includes history, review of systems, physical examination, and tests & measures.

Evaluation

PT’s interpretation and synthesis of examination findings leading to a diagnosis, prognosis, and management plan.

Diagnosis (PT)

Label describing clusters of signs, symptoms, or impairments to guide appropriate interventions.

Prognosis

Predicted optimal level of improvement and time frame expected for functional recovery.

Intervention

Purposeful interaction of PT with the individual to produce changes in condition consistent with diagnosis and prognosis.

Outcomes

Actual results of the management plan indicating impact on functioning, health, and quality of life.

Biopsychosocial Model

Approach stating that health status results from interactions among biological, psychological, and social factors.

ICF Model

WHO framework linking health condition with impairments, activity limitations, and participation restrictions.

Evidence-Based Practice

Integration of best research evidence, clinical expertise, and patient values in decision making.

Quality Measurement

Use of metrics to document service delivery processes, outcomes, and efficiency.

Episode of Care

All PT services provided in an unbroken sequence for a given condition or problem.

Visit

Single PT encounter or treatment session within an episode of care.

Direct Access (Self-Referral)

Patient-initiated PT services without prior physician referral, as allowed by state practice acts.

Co-Manage

PT collaborates with other professionals to coordinate an individual's management.

Consult

Providing or receiving expert opinion to identify problems or recommend solutions.

Manage (with Assistive Personnel)

PT remains accountable while delegating services to qualified support staff.

Refer

Directing an individual to another provider for services beyond PT’s scope or for specialized testing.

Patient

Individual receiving PT services for a disease, disorder, or impairment.

Client

Individual, business, or organization engaging PT services for consultation, prevention, or wellness.

Community

Group sharing common interests that may benefit from PT population-based services.

Population

Demographically defined group, e.g., by age, ethnicity, or socioeconomic status, targeted for PT interventions.

History (Subjective)

Systematic gathering of patient-reported information through interview or questionnaires.

Review of Systems

Screening of major body systems to identify symptoms warranting medical referral.

Red Flag

Sign or symptom indicating possible serious pathology requiring immediate referral.

Systems Review

Brief hands-on screening of cardiovascular, integumentary, musculoskeletal, neuromuscular, and communication domains.

Tests & Measures

Specific procedures used to quantify impairments, activity limitations, and participation restrictions.

Reliability

Degree to which a measurement is consistent and repeatable.

Validity

Extent to which a measurement accurately reflects the concept it intends to assess.

Outcome Measure

Standardized test or tool used at beginning and end of care to document change attributable to PT.

Impairment

Problem with body function or structure such as decreased strength or ROM.

Activity Limitation

Difficulty executing tasks or actions, e.g., walking or bed mobility.

Participation Restriction

Problem experienced in life roles such as work duties or family responsibilities.

Short-Term Goal (STG)

Measurable, functional target achievable in days or visits that leads toward long-term goal.

Long-Term Goal (LTG)

Expected functional outcome at discharge, usually achieved in weeks or months.

Management Plan / Plan of Care

Document detailing goals, prognosis, interventions, duration, frequency, and referral needs.

Procedural Interventions

Hands-on or task-specific treatments such as manual therapy, therapeutic exercise, and biophysical agents.

Adaptive / Assistive Technology

Equipment or devices that enhance function, e.g., walkers or sliding boards.

Therapeutic Exercise

Planned physical movements to remediate impairments and improve fitness and function.

Manual Therapy

Skilled hand techniques including mobilization and manipulation to improve tissue extensibility and motion.

Functional Training

Practice of tasks to improve daily activities such as gait, transfers, and ADLs.

Integumentary Repair Techniques

Interventions focused on wound care and skin protection.

Primary Prevention

Health promotion services aimed at preventing injury or disease in healthy populations.

Documentation

Written or electronic record of patient care that reflects PT’s decision-making and services provided.

Defensible Documentation

Complete, accurate, and timely records that justify necessity, support billing, and withstand legal scrutiny.

Approved Abbreviations

Facility or professional list of accepted shorthand to avoid errors and denial of payment.

Initial Examination/Evaluation Note

Comprehensive first documentation capturing history, systems review, tests, evaluation, and plan of care.

Progress Note

Periodic report comparing current status to prior findings, updating goals and interventions.

Daily (Visit) Note

Record of each treatment session detailing interventions, patient response, and plan for next visit.

Discharge Summary

Final evaluation summarizing progress, goal achievement, current status, and follow-up recommendations.

SOAP Note

Documentation format: Subjective, Objective, Assessment, Plan.

Subjective Section

Patient’s self-report of status, symptoms, goals, and response to previous care.

Objective Section

Measurable data obtained by the therapist including tests, measures, and observations.

Assessment Section

Professional judgment summarizing clinical impression, progress, and need for continued skilled care.

Plan Section

Upcoming interventions, frequency/duration, education, equipment, and referrals.

Informed Consent

Process where patient receives information about interventions, benefits, risks, and alternatives before agreeing to care.

Skilled Care

Services requiring PT’s clinical reasoning and specialized knowledge, beyond unskilled maintenance.

SMART Goal

Specific, Measurable, Achievable, Relevant, Time-bound statement guiding therapy objectives.

Outcome vs Test & Measure

Same tools; designated ‘outcome measure’ when used at start and end of care to show change.

Direct Access State Practice Act

Legislation defining how and when patients may seek PT services without referral.

Quality Assessment

Ongoing evaluation of service effectiveness, efficiency, and patient satisfaction.

Clinical Decision-Making

Cognitive process PTs use to integrate evidence, patient data, and experience to plan care.

Problem List

Catalog of patient-identified and non-patient-identified issues guiding goal setting and intervention selection.

Measure Categories (26)

APTA list including balance, gait, pain, ROM, muscle performance, etc., for standardized assessment.

Reliability (Test-Retest)

Consistency of a measure when repeated under identical conditions.

Validity (Construct)

Extent to which a test measures the theoretical concept it claims to measure.

Assistive Personnel

Individuals such as PTAs or aides who perform tasks under PT supervision.

Co-Signature

PT’s legal sign-off confirming review and approval of documentation created by students or assistants.