HOSA - Glossary - Profession

Assessment

Evaluation and judgmentof a patient’s status, ability, or current function.

Diagnosis

Final interpretation of findings based on examinations.

Direct Access

Availability of the PT to any-one seeking physical therapist services with-out referral by another health care provider.

Discharge

termination when goals have been achieved

Discontinuation

termination when goals have NOT been achieved (bc financial reasons, further intervention will not help)

Ergonomics

when you make work place conditions better suited

Evaluation

Clinical judgment based on an examination.

Examination

Process of gathering information about the past and current status of the patient or client.

Goals

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.

Intervention

Procedure conducted with the patient or client to achieve the desired outcomes.

Plan of care

Goals, interventions (including duration and frequency), desired out- comes, and criteria for discharge.

Primary Care

Prognosis 

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

Screening

Procedures to determine if there is a need for further services of a PT or other health care professional.

Secondary care

Services provided by individuals on a referral basis.

SOAP note

Documentation format taken from the Problem-Oriented Medical Record System. Its components are: (1) Subjective (what the patient or family member describes), (2) Objective (what the PT observes or measures), (3) Assessment (clinical judgment based on evaluation; includes goals), and (4) 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.

work-conditioning program

getting body ready for work

work-hardening program

getting the body and mind ready for the specific job.