Physical Therapy Documentation, SOAP Notes, and Imaging

A set of vocabulary flashcards covering key terms related to physical therapy documentation, SOAP notes, and imaging concepts from the lecture notes.

SOAP note

A structured documentation format in physical therapy: Subjective, Objective, Assessment, Plan.

Subjective

Part of SOAP noting background information and patient-reported data, not necessarily verifiable facts.

Objective

Part of SOAP containing measurable, observable data and test results; concrete facts.

Assessment

Part of SOAP with clinical judgment, interpretation of data, and progress toward goals.

Plan

Part of SOAP detailing treatment plan, frequency/duration, and future steps.

PT diagnosis

The physical-therapy-focused diagnosis, typically a combination of impairments and activity limitations.

Medical diagnosis

The physician-identified pathology, disease, or injury; not the PT diagnosis.

Examination

Data gathering by the PT, including medical history and systems overview, plus tests and measures.

Evaluation

Clinical judgment derived from the examination data; leads to diagnosis and prognosis.

Intervention

Purposeful PT actions (e.g., exercises, modalities, gait training) to produce change.

Prognosis

Predicted level of function and rehab potential for a patient.

MMT

Manual Muscle Testing; evaluation of muscle strength.

AROM

Active Range of Motion; motion performed by the patient.

PROM

Passive Range of Motion; motion performed by the clinician when the patient cannot move the joint.

Goniometry

Measurement of joint angles to quantify range of motion.

Modality

Therapeutic techniques used by PTs (e.g., cryotherapy, electrical stimulation, ultrasound) to aid healing or function.

Documentation

Systematic recording of patient data; essential for justification and insurance reimbursement.

Abbreviation (medical)

Shortened forms; use facility-approved abbreviations; when unsure, spell it out.

Imaging studies

Tests to visualize internal structures (X-ray, CT/CAT, MRI, ultrasound, radionuclide scanning, fluoroscopy).

X-ray (radiography)

Imaging using electromagnetic radiation to view bones and hardware; dense structures appear white.

CT scan (computed tomography)

3D X-ray imaging; quick and good for bone detail and certain pathologies; faster than MRI.

MRI

Magnetic resonance imaging; excellent soft-tissue detail; best for nervous system; expensive and claustrophobic.

Diagnostic ultrasound

Ultrasound used for imaging; creates pictures of tissues and organs.

Therapeutic ultrasound

Ultrasound used as a treatment to improve tissue extensibility and warmth; not an imaging study.

Radionuclide scanning

Nuclear imaging using radioactive tracers to assess metabolic activity in tissues.

Fluoroscopy

Real-time X-ray imaging used during procedures to guide injections or device placement.