The following glossary is essentially limited to terms which involve the process of documentation. In addition, definitions are suggested for some terms which are used in so many different contexts, [such as acute and chronic] that they have become difficult to define accurately.
AAROM: Active assisted range of motion. The patient is asked to perform voluntary movement of the joint throughout its arc of movement, and the examiner applies a mild force in the same direction as the patientís movement. The purpose is to ensure that full range of motion has been measured, and to assess the quality of the joint movement upon reaching the endpoint of movement.
Acute: having symptomatology for a relatively short length of time. A common definition is symptoms which are noticed for less than 6 weeks upon presentation. 1
AROM: Active range of motion, performed with the patient voluntarily moving the joint. The examiner is looking for differences in range of motion and the patientís willingness to perform the movement. 2
Assessment: The portion of the patient clinical record which details the doctorís impression, diagnosis or opinions of the case.
Chief complaint: The patientís primary health concern which results in seeking treatment from the doctor.
Chronic: having symptomatology for an extended length of time. A commonly accepted criteria for a chronic complaint is symptomatology which are apparent for more than 16 weeks upon initial presentation. 3
Disability: The alteration of an individualís capacity to meet personal, social or occupational demands, or statutory or regulatory requirements because of an impairment. Disability refers to an activity or task the individual cannot accomplish. 4 Disability is the inability to perform specific work-related activities. Disability is a functional deficit.
Impairment: The loss, loss of use or derangement of any body part, system, or function. Impairments are defined as conditions that interfere with an individualís "activities of daily living", or the inability to perform certain physical tasks, which may or may not be associated with work activities. 4 An impairment is an anatomic deficit.
Maintenance care: a. Treatment given in the absence of significant symptomatology; b. well-person care; c. preventative or prophylactic care
Objective: Items in the patient record which can be accurately and repeatedly measured.
OPQRST: A mnemonic device for the essential elements of the history of the present illness. The initials represent: onset, palliative and provocative factors, quality of pain, radiation, severity, and timing (frequency).
Plan: Treatment plan; a written outline of the proposed care for the patient
PROM: Passive range of motion. The patient is asked to relax as much as possible, and the examiner supplies all the force necessary to move the joint throughout its arc of movement. Passive testing is usually performed if deficits in active range of motion are noted.
SOAP: A mnemonic for subjective, objective, assessment, plan.
Sub-acute: symptoms which are present for a period greater than an acute presentation, and less than a chronic presentation. A commonly accepted definition of sub acute would be the presence of symptomatology for 6-16 weeks upon initial presentation.
Subjective: Items in the patient record which are derived from the patientís verbal or written communications with the doctor.
Supportive care: a. Treatment provided after the patient has reached maximum medical/chiropractic improvement and has not reached a full recovery; b. treatment given to diminish permanent or chronic symptomatology when a full recovery is not possible; c. treatment provided to alleviate the symptomatology of a known anatomic deficit.
1. Fromeyer J. Back Pain and Sciatica. N Engl J Med., 318:291-300, 1988
2. Magee D. Orthopedic Physical Assessment. WB Saunders, Philadelphia, 1992.
3. Mayer T, Gatchel R. Functional restoration for spinal disorders: a sports medicine approach. Leee & Febiger, Philadelphia, 1988.
4. American Medical Association. Guides to the evaluation of permanent impairment, 4th ed. AMA, Chicago, 1993.
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