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Prevalence
- # of cases of a disease in existence at a certain time in a designated area
- (ex) Cerebral Palsy: 2 in 1000, Mental Retardation: 2-3% of the population
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Incidence
- To occur/happen
- Rate of which a certain event occurs
- Number of new cases of a disease occuring during a certain period
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Etiology
The study or theory of the causation of any disease
(ex) believed that some cancers start as error in cell division
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Pathogenesis
The development of morbid conditions or of disease
(ex) build up of plaques on blood vessels leads to heart attacks (atherosclerosis-->Myocardial Infarction-MI)
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Hereditary
- Derived from ancestry or obtained by inheritance
- Genetic transmssion of a particular quality or trait from parent to offspring
(ex) Eye Color/ Muscular Dystrophy
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Familial
- Occurring in or affecting different members of the same family
- Genetic predisposition, but NOT hereditary
(ex) alcoholism, heart disease
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Congenital
- Existing at/before birth
- Conditions that are present at birth, regardless of their causation
(ex) Cerebral Palsy, limb deformities, cleft palate
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Prognosis
Forecast as to the probable result of a disease: The prospect of recovery or outcome of a disease as indicated by the nature and symptoms of the case
(ex) Cancers caught early have good prognosis for cure
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Soap Note
O
A
P
Format most used for CHARTING
- S: Subjective
- O: Objective
- A: Assessment
- P: Plan
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Subjective
- Feeling, temperment, perception existing or originating in the mind of the observer
- cannot be measured or verified
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Objective
- Observable, measureable, determined w/o bias or prejudice--FACT
- Evaluation, treatment, ect
- Anything the medical professional sees, feels, measures, or does to the patient is documented in this section
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Assessment
- Medical professional makes a judgement of the data collected in S and O portions of the note
- Diagnosis or prognosis is put here
- Long & short terms goals, and treatment plan are specified or revised here
- This is the place for the medical Professionals throughts and perceptions about the patient
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Plan
- Document of how medical professional is going to treat the patient
- Document anything one is going to do for the patient. This would include establishing, continuing, changing, discontinuing or contacting someone about the plan of care
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PT
Physical Therapist/Physical Therapy
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RPT
Registered Physical Therapist
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PTA
Physical Therapist Assistant
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Min. PA
Minimal Physical Assistance
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Mod. PA
Moderate Physical Assistance
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Max. PA
Maximal Physical Assistance
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HEP
Home Exercise Program
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Flex. or (check mark)
Flexion
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ER or Ext. Rot.
External Rotation
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IR or Int. Rot.
Internal Rotation
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Pron.
Pronate or Pronated
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Sup.
Supinated or Supinated (may also be Superior, look at content for verification)
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E. Stim or elec. Stim
Electrical Stimulation
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FES
Functional Electrical Stimulation
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HVGS
High Voltage Glavanic Stimulation
- electrical therapy used for womb care, decreases pain
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PB
Paraffin Bath
-Hot wax hair removal used with rheumatoid arthritis patients
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SWD
Short Wave Diathermy
-Type of Electromagnetic Wave
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TENS or TNS
Transcutaneous Electrical Stimulation
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UVR
--MED
--SED
- UltraViolet Radiation
- --Minimal Erythermal Dose
- --SubErythermal Dose
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AAROM
Active Assitive Range of Motion
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AROM
Active Range of Motion
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PRE
Progressive Resistive Exercise
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PROM
Passive Range of Motion
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Ther. Ex.
Therapeutic Exercise
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Wms. Ex.
Williams Exercises
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AFO
Ankle Foot Orthosis
--Brace that keeps foot at a 90o angle
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HKAFO
Hip Knee Ankle Foot Orthosis
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KAFO
Knee Ankle Foot Orthosis
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LBQC
Large Base Quad Cane
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PTB
Patellar Tendon weight Bearing
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SBQC
Small Base Quad Cane
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TLSO
Thoracic Lumbar Sacral Orthosis
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Amp
AE or A/E
BE or B/E
AK or A/K
BK or B/K
- Amputation
- --Above Elbow
- --Below Elbow
- --Above Knee
- --Below Knee
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AODM
Adult Onset Diabetes Mellitis
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AVM
- ArterioVenous Malformation
- --blood doesnt pump back to the heart
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CAD
Coronary Artery Disease
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CHF
Congestive Heart Failure
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COPD
Chronic Obstructive Pulmonary Disease
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Hemi
Hemiplegia or Hemiparesis
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IDDM
Insulin Dependent Diabetes Mellitis
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JRA
Juvenile Rheumatoid Arthritis
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MVA
Motor Vehicle Accident
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Para
Paraplegia or Paraparesis
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PE
Pulmonary Embolism (may also mean Physical Exam, look at context)
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Quad
Quadriplegia or Quadriparesis
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SLE
Systemic Lupus Erythematosis
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TBI
Traumatic Brain Injury
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THA
Total Hip Arthroplasty (replacement)
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TKA
Total Knee Arthroplasty (replacement)
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CABG
Coronary Artery Bypass Graft
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CT
Computerized axial Tomography (Cat Scan)
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MRI
Magnetic Resonance Imaging
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NVC
Nerve Conduction Velocity
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ORIF
Open Reduction Internal Fixation
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PET
Position Emission Tomography
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PT
Prothrombin Time (may mean Physical Therapy)
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PTT
Partial Thromoboplasmin Time
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RAM
Rapid Alternating Movements
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ER
Emergency Room or External Rotation
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T/A/D
Tobacco, Alcohol, Drugs
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Tx or Rx
Treatment (Rx usually means Prescription)
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ANS
Autonomic Nervous System
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CNS
Central Nervous System
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DIP
Distal InterPhalangeal
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PIP
Proximal InterPhalangeal
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PNS
peripheral Nervous System
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Sup.
Superior or Supination
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D/C or DC
Discharge or Discontinue
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PWB
Partial Weight Bearing
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TTWB
Toe-Touch Weight Bearing
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WBAT, WBTT
Weight Bearing As Tolerated (if unsure, check with doctor)
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LOC
Loss Of Consciousness
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MAEW
Moves All Extremeties Well
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PERRLA
Pupils Equal Round and Reactive to Light and Accomodation
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WFL
Within Functional Limits
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DME
Durable Medical Equipment
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ECF
Extended Care Facility
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