DOCUMENTATION CHAP 1

100 vocabulary flashcards covering key terms and definitions related to disablement and physical therapy documentation as presented in the notes.

Disablement

The dynamic process by which disease or condition leads to functional consequences in body systems, tasks, and social participation over time.

ICF

a WHO framework providing a uniform language to describe health beyond diagnosis.

ICD-10

International Classification of Diseases, Tenth Revision

ICD-10

the diagnostic classification standard for diseases and related health conditions.

ICF Part 1

Functioning and Disability; includes body functions, body structures, activities, and participation.

ICF Part 2

Contextual Factors; includes environmental and personal factors.

Body Functions

Physiological functions of the body (including psychological functions).

Body Structures

Anatomical parts of the body such as organs and limbs.

Impairments

Problems with body functions or structures, such as deviations or losses.

Activities

The execution of a task or activity by an individual.

Activity Limitations

Difficulties that might be encountered when attempting to complete a task or carry out an activity.

Participation

Involvement in a life situation, such as work or school.

Participation Restrictions

Problems an individual might face while involved in life situations.

Contextual Factors

The complete factors that make up a person’s life and living, including background.

Environmental Factors

External factors in which people live and carry out their lives; can facilitate or hinder participation.

Personal Factors

Individual-specific factors such as age, gender, social habits, health habits, upbringing, and coping strategies.

Biomedical Model

A traditional health model where health means absence of disease and treatment targets biological defects.

Health

The state described by the biomedical model as free or absent from disease.

Health-Related State

A broader concept of health used by the ICF to include health conditions and their impact on functioning.

Functioning

What the individual can do; positive aspects of health.

Disability

What the individual cannot do; negative aspects of health.

Positive Aspects of Health

The functioning and abilities an individual can perform.

Negative Aspects of Health

Impairments, limitations, and restrictions that hinder function.

ICF Part 1

Body Functions and Structures; Activities and Participation.

ICF Part 2

Contextual Factors, including Environmental and Personal Factors.

Body Level

What the body can do; intact body functions and structures.

Individual Level

Tasks and actions that an individual can perform.

Societal Level

Roles and activities in life situations at the community level.

Environment

External influences on functioning, including home, workplace, and larger social context.

Facilitators

Environmental factors that support or enable participation.

Barriers

Environmental factors that hinder participation.

ICF

describes function and disability

Bed Mobility

An activity area; part of functional assessment of daily tasks.

Transfers

Moving between surfaces; part of functional assessment.

Hygiene

Personal care activities included in functional assessment.

Self-Care

Basic personal care tasks.

Home Management

Domestic tasks like yard work and household cleaning.

Play

Participation domain involving recreation and leisure.

Community Activities

Participation domain such as going to the store or bank.

Impairments

Examples include limitations in ROM, strength, endurance, or balance.

Pathology

The disease or condition that can lead to impairments.

ICD-10

catalogs diagnoses

WHO Family of International Classifications

WHO classification family that includes ICF and ICD-10.

Documentation

Medical record keeping; any entry into the health record identifying care or response to intervention.

Initial Examination

First examination documenting baseline functioning and disability.

Progress Notes

Ongoing notes documenting patient progress.

Flow Sheets

Time-series records used in documentation.

Checklists

Structured lists used in documentation.

Re-examination Reports

Documentation of re-evaluation outcomes.

Summations of Care

Summaries of interventions and patient responses.

Consultation Reports

Documentation of consultations with other clinicians.

Physician Prescriptions

Prescriptions included in patient documentation.

Certification

Certifications included in documentation.

Patient Instructions

Guidance provided to patients about care and home programs.

Interdisciplinary Notes

Notes from other disciplines included to support interventions.

Disablement in Documentation

Reflecting impairment, activity limitations, and participation restrictions in notes.

Impact of Impairments on Activity

Describing how impairments relate to activity limitations and participation restrictions.

Three Disablement Concepts for Documentation

Document impairment and activity/participation limitations, relate impairments to activity restrictions, and show how interventions change these domains.

Pathway from Pathology to Functional Outcome

A framework describing how disease leads to functional consequences and participation changes.

Functional Performance

The ability to perform daily tasks and activities in real life contexts.

Life Areas

Domains such as personal care, work, school, play, and community.

Life Situations

Contexts in which daily activities occur.

Capacity

Executing tasks in a standard environment

Performance

Executing tasks in the current environment

Environmental Context

Physical structures, social attitudes, and policies affecting functioning.

Personal Factors

Internal attributes that influence functioning.

Government Agencies

Part of the environmental context that can assist people with disabilities.

APTA

endorsed ICF language in 2008; publications updated accordingly.

APTA Practice Guide Reference

APTA resources (Guide to PT Practice) used for framing documentation and practice.

Documentation Purpose

Documentation should reflect disablement and support clinical decisions.

ICF

provides a common language for physical therapists to communicate about health and disability.

Clinical Documentation & Disablement

Integrating disablement concepts into notes to show how pathology affects daily life.

Flow of Documentation

Entries from initial exam through progress notes and re-examinations to reflect patient change.

Disease

refers to pathology

Disability

refers to functional outcome and participation.

Family of Classifications (WHO)

WHO group including ICF and ICD-10 used to describe health in multiple dimensions.

Exercise Program Documentation

Inclusion of home exercise programs and instructions in medical records.

Interdisciplinary Collaboration

Notes from multiple disciplines integrated into the patient record.

Participation in Society

Involvement in work, school, recreation, and community activities.

Contextual Factors

Environmental and personal factors that influence functioning and disability.

Health-Related State Description

A state described within ICF beyond the disease diagnosis.

Health Outcome Measures

Outcomes that reflect functioning and disability, not just impairment.

Clinical Architecure

Architectural framework for research, policy, and clinical care in disablement.

Activities

Typical PT activity examples used to assess daily living tasks.

Activity Examples

Bed Mobility, Transfers, Hygiene

Participation

Life roles commonly examined in PT practice.

Participation

Work, School, Play

Community Activities

Examples like grocery store or bank attendance to illustrate participation.

Clinical Language Consistency

The goal of standardizing terms to describe patient function.

Functioning

represents positive health

disability represents negative health.

represents negative health.

ICD-10 as Catalog of Diseases

Systematic listing of diseases, disorders, injuries, and related conditions.

ICF as Complement to ICD-10

Using ICD-10 for diagnosis and ICF for function/disability together.