DOCUMENTATION MEDICAL TERMINOLOGY MEDICAL TERMINOLOGY • WHY ARE ABBREVIATIONS, SYMBOLS AND ACRONYMS USED IN HEALTH CARE? MEDICAL TERMINOLOGY • PRONE • SUPINE • INFLAMMATION • HYPERTONIC VS. HYPOTONIC • ETC… MEDICAL TERMINOLOGY AND ABBREVIATIONS • MAKE FLASH CARDS ASSIST A AFTER p abd. •ABDUCTION ADL’s •ACTIVITIES OF DAILY LIVING Add. •ADDUCTION AROM •ACTIVE RANGE OF MOTION AKA •ABOVE KNEE AMPUTATION @ •AT BILATERAL B BKA •BELOW KNEE AMPUTATION BIW •BI-WEEKLY, TWICE WEEKLY CG •CONTACT GUARD CP •COLD PACK C/O •COMPLAINS OF DC •DISCHARGE DF •DORSIFLEXION DX •DIAGNOSIS ER •EXTERNAL ROTATION FWB •FULL WEIGHT BEARING FX •FRACTURE HEP •HOME EXERCISE PROGRAM HX •HISTORY INDEPENDENT I IE •INITIAL EVALUATION IR •INTERNAL ROTATION LEFT L LBP •LOW BACK PAIN LE •LOWER EXTREMITY LTG •LONG TERM GOAL MHP •MOIST HOT PACK MMT •MANUAL MUSCLE TEST NWB •NON WEIGHT BEARING PF •PLANTAR FLEXION PMH •PAST MEDICAL HISTORY Pt. •PATIENT PWB •PARTIAL WEIGHT BEARING RIGHT R Reps •REPETITIONS Rx. •TREATMENT SBA •STANDBY ASSIST SI, SIJ •SACROILIA JOINT STG •SHORT TERM GOALS TENS •TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION THR •TOTAL HIP REPLACEMENT TIW •THREE TIMES A WEEK TKR •TOTAL KNEE REPLACEMENT UB •UPPER BODY UE •UPPER EXTREMITY WB •WEIGHT BEARING WBAT •WEIGHT BEARING AS TOLERATED WNL •WITHIN NORMAL LIMITS WITHOUT s WITH c CHANGE INCREASE/DECREASE CHIEF COMPLAINT •CC AS NEEDED •PRN SIDELYING •S/L STRAIGHT LEG RAISE •SLR SIDEBEND •SB LUMBAR SPINE •L/S CERVICAL SPINE •C/S ILIO-TIBIAL BAND •ITB STANDARD WALKER •SW ROLLING WALKER •RW THERABAND •T-Band PRACTICE… • Pt. c/o LBP along the R side. _ • Rx c MHP • Pt. given HEP. S.O.A.P. NOTES S.O.A.P. NOTES • SUBJECTIVE • OBJECTIVE • ASSESSMENT • PLAN S.O.A.P. NOTES • WHAT IS THE DIFFERENCE BETWEEN SUBJECTIVE INFORMATION AND OBJECTIVE INFORMATION? • HOW IS EACH IMPORTANT IN DOCUMENTATION? S.O.A.P. NOTES • THE “SUBJECTIVE” PART OF THE SOAP NOTE: • IS WHERE YOU WRITE WHAT YOUR CLIENT HAS TO SAY ABOUT HIS OR HER CURRENT CONDITION. "I CAN NOW BEND MY BACK TO PUT ON MY SOCKS AND SHOES FOLLOWING MY TREATMENT SESSION YESTERDAY." IT IS BETTER IF THE PATIENT'S SUBJECTIVE STATEMENT IS MORE SPECIFIC. • "THE PAIN ON MY BACK HAS MOVED DOWN TO 3/10 FROM THAT OF YESTERDAY BEFORE MY TREATMENT." S. O.A.P. NOTES • THE "OBJECTIVE" PART INCLUDES ALL THE MEASUREMENTS THAT YOU'VE OBTAINED FROM YOUR CLIENT. • THIS INCLUDE THE VITAL SIGNS, MANUAL MUSCLE TESTING MEASUREMENTS, JOINT RANGE OF MOTION MEASUREMENTS, ETC. THE SPECIFIC PHYSICAL THERAPY TREATMENTS ARE ALSO INCLUDED IN THE OBJECTIVE PART. THE TREATMENT SHOULD INCLUDE THE SPECIFIC WEIGHT, REPETITIONS, INTENSITY AND DURATION. S. O.A.P. NOTES _ • ® KNEE EXTENSION- FULL ROM; 10 REPS X 3 SETS c 5 LBS. ANKLE WEIGHT • MHP ON B LUMBAR AREA x 20 MINUTES S.O. A.P. NOTES • ASSESSMENT THIS IS WHERE THE PHYSICAL THERAPIST WRITES HIS/HER IMPRESSION REGARDING PATIENT'S CURRENT SITUATION SINCE LAST VISIT. • THIS MAY ALSO INCLUDE THE THERAPIST'S PERSPECTIVE ON WHETHER A PARTICULAR TREATMENT WILL BE CONTINUED OR MODIFIED ACCORDING TO CLIENT'S NEEDS. EXAMPLE: "The Pt. tolerated the Rx well but needs frequent verbal cues from PT to complete knee extension at full ROM." S.O.A. P. NOTES • PLAN IN THE PLAN PART, THE PHYSICAL THERAPIST WRITES THE PLANS FOR THE CLIENT'S NEXT THERAPY VISIT. SAMPLE SUBJECTIVE DATA • 24 y/o male c/o L ankle pain. Pt. states he was playing basketball this morning, when he jumped to block a pass and "came down funny" on his ankle. He states pain goes from a dull 2 out of 10 to a sharp 6 out of 10 when he applies pressure. Pt. has no allergies to medications, and is currently taking Advil for a previous injury of R knee. THE KNEE -Largest joint in the body. -Hinge joint -greatest ROM is in flexion -highly susceptible to injury -not protected by layers of fat and muscle -easily palpable THE KNEE (ANTERIOR) THE KNEE (POSTERIOR) THE KNEE THE KNEE THE KNEE BURSAs KNEE LIGAMENTS • HTTP://YOUTU.BE/RRVAJHJXMX8 • HTTP://YOUTU.BE/HWNFGM6JIKY • HTTP://YOUTU.BE/OUIIXMGTLYI