CLINICAL SUBJECTS

Documentation Basics for the Physical Therapist Assistant Third Edition

Documentation Basics for the Physical Therapist Assistant Third Edition

Documentation Basics for the Physical  Therapist Assistant Third Edition

Documentation Basics for the Physical Therapist Assistant Third Edition After reading this chapter, the reader will be able to do the following:

1. Define disablement.
2. Define terminology used in the International
Classification of Functioning, Disability and Health
(ICF).
3. Differentiate between impairment, activity limitation,
and participation restriction.
4. Define documentation.
5. Describe the need for common language in physical
therapy documentation.
6. Describe how disablement concepts can be integrated nto physical therapy documentation.

A traditional approach to defining a person’s health  comes from the biomedical model in which health means
free or absent from disease.1 The biomedical model implies
that accurate diagnosis and identification of the patient’s biological defects can directly lead to selection of interven-
tions that will maximize health outcomes.1 In this model,
however, there is little emphasis on how the disease affects the person’s ability to function orparticipate within society
on a daily basis. Over the last few decades, many rehabilitation professionals have shifted their focus away from  managing the disease or pathology and have moved toward  managing the consequences of the disease or condition.

It has become more common to focus on these consequences  as they pertain to the individual’s ability to carry out tasks and function within society. Assessing functional perfor-
mance and describing functional status are now primary components of the physical therapist’s examination of the
patient. Verbrugge and Jette2 described the consequences  that chronic and acute conditions have on specific body  system function and on a person’s ability to act in necesary, usual, expected, and personally desired ways in his  or her society as disablement. These authors explained that  disablement is a “process,” indicating that it is dynamic, or  a trajectory of functional consequences over time. A more  contemporary approach to physical therapy patient man- agement is to incorporate disablement and disablement
concepts.

Documentation Basics for the Physical Therapist Assistant Third Edition

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