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18 Terms
Soap
Subjective, objective, assessment, plan
Subjective
What pt reports, history symptoms pt reported outcome
Objective
What physical therapists test, measure treatment/intervention, signs, systems review
Assessment
Integration of info prognosis, goals outcome
6 elements of patient/client management model
Examination, evaluation) diagnosis,prognosis,intervention, outcome
Examination
Pt history1symptoms1tests, measures
Evaluation
Information integration
Diagnosis
Identifying illness
Prognosis
Predict course of condition
Intervention
Action taken to change prognosis
Outcome
Result of intervention
Plan
Next visit, discharge referral
Symptom
Severity, irritability nature stage stability
Severity
Numeric pain rating scale
Irritability
How quickly it starts/stops
Nature
Describe pain
Stage
acute, subacute, chronic
Stability
Improving, stable worsening