Intro to Health Care Systems - Chapter 2

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20 Terms

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diagnosis

a categorization of the examination findings through a defined process

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direct access

availability of the PT to anyone seeking physical therapist services without referral by another health care provider

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electronic health record

  • health-related information about an individual that conforms to national standards and is entered and stored electronically

  • can be accessed by different health care organizations

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episode of care

care provided for a specific condition over a set period of time

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evaluation

  • a clinical judgment based upon the findings from the examination phase

  • integrally linked to establishing a diagnosis, prognosis, and plan of care

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examination

the process of gathering information about the individual’s past and current status

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goal

measurable, functional objective linked to a problem identified in a patient evaluation

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history

description of the past and current health status of the patient or client

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interprofessionalism

  • patient-centered care provided by an interdisciplinary team

  • promotes interdisciplinary education

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intervention

procedure conducted with the patient or client to achieve the desired outcomes

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outcomes

the result of the interventions and entire plan of care

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plan of care

goals, interventions (including duration and frequency), desired outcomes, and criteria for discharge

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primary care

the level of health care delivered by a member of the health care system who is responsible for the majority of the health needs of the individual

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prognosis

a prediction of the ultimate level of improvement in function and the length of time necessary to reach that level

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secondary care

services provided by individuals on a referral basis

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SOAP note

  • documentation format taken from the Problem-Oriented Medical Record System

  • Components: Subjective (what the patient or family member describes), Objective (what the PT observes or measures), Assessment (clinical judgement based on evaluation; includes goals), and Plan of care

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Standards of Practice for Physical Therapy

document approved by the House of Delegates of the APTA that identifies conditions and performances essential for the provision of high-quality physical therapy

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systems review

brief examination to provide information about the general health of the patient or client, including their physiologic, anatomic, and cognitive status

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tertiary care

service provided by specialists who are commonly employed in facilities that focus on particular health conditions

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tests and measures

specific procedures selected and performed to quantify the physical and functional status of the patient or client

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