Communications (Introduction to Documentation) Flashcards
What are the 5 Domains to the ICF model?
- body function
- body structures
- activity and participation
- environmental factors
- personal factors
Body function (Component of ICF)
A persons ability to perform an activity. For example, back pain interferes with function, there it is categorized as body function.
Body structure (Component of ICF)
-Related to the anatomical or physiological body part related to a patients disability or disease.
Personal Factors (Component of ICF)
-Items related to age, race, occupation, etc.
Activity and participation (Component of ICF)
-What the patient can do related to his or her ability to function.
What is a Medical Diagnosis?
-Systemic disease or disorder determined by MD
What is a Treatment Diagnosis?
-Identification of pathokinesiologic problems.
What is a performance qualifier?
-What a patient can do in his or her current environment.
What is a Capacity qualifier?
-Indicates the patient’s ability to perform a task or activity.
What does PSPG stand for?
Problem, Status, Plan, Goals.
What does PSP stand for?
Problem, status, plan
What does POMR stand for?
Problem Oriented Medical Records.
What does DEP stand for?
Data, Evaluation, Performance.
What is SOMR and what does it stand for?
Source Oriented Medical Records. Organized by the department delivering the services to the patient. Each provider will document in their specific section.
