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diagnosis
a categorization of the examination findings through a defined process
direct access
availability of the PT to anyone seeking physical therapist services without referral by another health care provider
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
episode of care
care provided for a specific condition over a set period of time
evaluation
a clinical judgment based upon the findings from the examination phase
integrally linked to establishing a diagnosis, prognosis, and plan of care
examination
the process of gathering information about the individual’s past and current status
goal
measurable, functional objective linked to a problem identified in a patient evaluation
history
description of the past and current health status of the patient or client
interprofessionalism
patient-centered care provided by an interdisciplinary team
promotes interdisciplinary education
intervention
procedure conducted with the patient or client to achieve the desired outcomes
outcomes
the result of the interventions and entire plan of care
plan of care
goals, interventions (including duration and frequency), desired outcomes, and criteria for discharge
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
prognosis
a prediction of the ultimate level of improvement in function and the length of time necessary to reach that level
secondary care
services provided by individuals on a referral basis
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
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
systems review
brief examination to provide information about the general health of the patient or client, including their physiologic, anatomic, and cognitive status
tertiary care
service provided by specialists who are commonly employed in facilities that focus on particular health conditions
tests and measures
specific procedures selected and performed to quantify the physical and functional status of the patient or client