Patient Client Management Model and Clinical Decision Making Vocabulary

Vocabulary practice cards covering the Patient Client Management Model, Goal Writing Frameworks, Clinical Decision-Making, Nagi Model, and ICF Framework.

Patient Client Management Model

A comprehensive clinical process framework consisting of Referral/Consultation, Examination, Evaluation, Diagnosis, Prognosis, Intervention, and Outcomes.

Direct Access

A patient referral pathway allowing individuals to receive physical therapy services directly without a prior physician order, subject to state practice act rules.

Review of Systems

A subjective screening checklist of symptoms across major body systems to identify comorbidities or determine if a medical referral is necessary.

Comorbidities

Co-existing medical conditions that may impact a patient's prognosis or ability to participate in physical therapy.

Clinical Communication Funnel

A history-taking model transitioning from open-ended narrative questions to semi-structured clarification questions, and finally to targeted closed-ended questions.

Systems Review

A brief hands-on examination by the physical therapist assessing objective signs across cardiovascular/pulmonary, integumentary, musculoskeletal, neuromuscular, and cognitive domains to plan detailed tests.

Evaluation

The clinical process of synthesizing and interpreting examination findings to establish a diagnosis, prognosis, indication for physical therapy, and plan of care.

Physical Therapy Diagnosis

A diagnostic label focusing on movement system impairments of body structure/function, activity limitations, and participation restrictions.

Medical Diagnosis

A diagnostic label identifying underlying disease processes, pathologies, or injuries primarily at the cellular, tissue, or organ level.

Prognosis

The physical therapist's prediction of a patient's optimal level of functional improvement over a designated episode of care.

Plan of Care

A strategic clinical outline specifying frequency and duration of visits, patient goals, selected interventions, contraindications, and discharge plans.

SMART Goals

Goal-setting parameters requiring goals to be Specific (patient-centered), Measurable, Attainable, Relevant (functional), and Time-bound.

ABCs of Goal Writing

A structural method ensuring functional goals contain an Audience, Behavior, Condition, and Degree.

Short-Term Goals

Incremental functional targets attained by a patient building toward long-term goals, typically set for a duration of $2$ to $3$ weeks.

Long-Term Goals

Final functional targets required for a patient to be safely discharged from physical therapy care, typically set for durations exceeding $3$ weeks.

Interventions

Purposeful, skilled physical therapy treatments executed to remediate impairments, improve functional performance, and promote health.

Outcome Measures

Standardized test instruments applied to quantify changes in functional status, impairments, or patient satisfaction throughout care.

Re-examination

The selective re-application of history and physical examination items to assess progress relative to initial findings during an episode of care.

Re-certification

A required modification of the Plan of Care—such as altered visit frequency, extended duration, or added interventions—that must be signed by the referring provider.

Re-evaluation

A formal re-assessment initiated when a patient presents with a significant change in status, new complaints, or additional medical orders.

Physical Therapy

Treatment delivered by physical therapists or assistants to improve movement function, manage pain and chronic conditions, and recover from or prevent injury and disease.

Skilled Care

Medically necessary physical therapy services requiring expert clinical judgment and decision-making that cannot be safely performed by non-professionals.

Recovery

A rehabilitation approach aimed at regaining lost physical abilities and restoration of normal movement patterns.

Compensation

The adoption of alternative functional strategies to complete tasks and fulfill participation goals without full physical recovery.

Prevention

Rehabilitation strategies focused on maintaining health, minimizing potential secondary problems, and preventing predictable physical decline.

Clinical Reasoning

The reflective thinking and decision-making processes clinicians use to integrate clinical data, evidence, and patient preferences into care.

Nagi Model

A disablement framework organizing health outcomes into Pathology, Impairment, Functional Limitation, and Disability.

Pathology (Nagi)

Cellular, homeostatic, or structural damage or disruption in tissue or body parts within the Nagi Disablement Model.

Impairment (Nagi)

Anatomical, physiological, or psychological loss or abnormality occurring at the organ, tissue, or body system level.

Functional Limitation (Nagi)

An inability or restriction in executing specific actions or activities at the level of the whole person.

Disability (Nagi)

An inability to perform expected or required social, work, and personal life roles.

ICF Model

The International Classification of Functioning, Disability, and Health enablement model created by the World Health Organization in 2001.

Body Structure and Function (ICF)

Anatomical body parts (structures) and specific physiological or psychological mechanisms (functions) evaluated for impairments.

Activity Limitation (ICF)

Difficulty encountered by an individual in executing specific daily functional tasks or actions.

Participation Restriction (ICF)

Problems experienced by an individual in engaging in or fulfilling meaningful life roles and social situations.

Facilitators

Environmental factors within the ICF framework that promote, support, or assist an individual's overall functioning.

Barriers

Environmental factors within the ICF framework that hinder, obstruct, or make an individual's daily functioning more difficult.

Personal Factors (ICF)

Individual characteristics such as age, gender, coping style, education, and health habits that influence condition management.