DOCUMENTATION 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.Pt. PATIENT

PWB PARTIAL WEIGHT BEARING

RIGHT R

Reps REPETITIONS

Rx.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 side. Rx c MHP Pt. given HEP. R _

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.

® 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

BURSAs

KNEE LIGAMENTS