clinical assessment Flashcards
why chart?
communication with other HCP
legal requirement
therapist self reflection
monitor progress in patient
database
guest records
indelible record consisting of … must be kept by registrant (CMT bylaws, Schedule D, standards of practise)
Patient’s name, address, dob
name of referring practioner(s)
date of each professional visit
name of therapist who gave treatment
updated health history
findings/clinical impressions
treatment plan
written reports received/sent from other HCP for patient
SOAP chart acronym
subjective
objective
action and analysis
plan
1) subjective (SOAP)
patient’s complaint
how patient describes own condition
their perception
2) objective (SOAP)
differences noticed by therapist
PGPM assessments:
postural assessment
gait assessment
palpation assessment
movement assessment
3) Action/analysis (SOAP)
which techniques used?
which body part treated?
result of session?
4) Plan (SOAP)
plan for future treatments
self-care routines – e.g. strengthening/stretching exercises
referral to other HCP
DAR charting
Data
Action
Result
1) Data (DAR)
combined subjective/objective
observation, palpation, movement etc
more condensed/brief compared to SOAP charting
2) Action (DAR)
similar to Action of SOAP
More condensed/brief compared to SOAP
3) Result (DAR)
similar to PLAN in SOAP, but more condensed/brief
outcome of treatment?
plan for future session
PAIN TENSION CYCLE
stress:
physical reaction to stressor
stressors:
e.g. from environment
e.g. body (illness)
e.g. perception
responses adding to stressors:
e.g. drugs/alcohol
chronic pain cycle
pain
immobilization
disability
self-esteem
depression
isolation/withdrawal
stress
muscle tension
pain
etc.
how does body respond to stress?
breathing pattern
circulation
nervous system
signs of stress
sleep
digestion
despair
fatigue
hostility
alcohol/drug use
danger/risk
TV
etc.
HOPMNRS and Gait
history
observation
palpation
(gait)
movement
neurological
referred pattern
special tests (BP/pulse)
Scope of practice: diagnosis
It is not in our scope of practice to diagnose
however, we can cautiously suggest that based on previous experiences and observations of patients, “we suspect, that it might be…” – and then refer to other HCP for clarification
Schedule D, CMTBC bylaws — a patient must…
perform comprehensive assessment according to HOPMNRS
formulate treatment plan
monitor vital signs as necessary – (pulse, BP, breathing rate, temperature)
must design treatment plan based on findings
design coach home-care program and ADL (activities of daily living)
Schedule E, CMTBC bylaws – why do we chart?
law
protect personal info
full name, gender, dob
address, phone #
name of registrant (therapist)
name(s) of referring HCP
medical history
insurance reports
clinical impression/findings
treatment plan
self-care/home-care
written in official language of Canada
.
Patient Legal Name (can create a space for preferable name)
Patient’s date of birth
Patient’s gender
Patient’s current living address
Patient’s Personal Health Number
Patient’s Family doctor
Patient’s contact information (phone numbers, email address, not social media)
Patient’s medical history
Patient’s previous injuries, illness, surgeries and current health concerns
additional info on intake sheet
consent for payment via software, sharing information with other Health care practitioners of the same clinic, diagnostic reports.
Cancellation policy
Late/No show Fees
RMT Fees
open vs closed ended questions
open ended = subjective info from patient
closed-ended = objective info from patient
initial interview =
You may want to briefly explain the process for today’s initial appointment.
Go over the intake form and ask questions about past and current LIFESTYLE
As you go along the interview, document the patient’s answers
CHIEF or PAIN BASED COMPLAINT questions (LMNOPRSTU….)
Use OPEN-ENDED AND CLOSE-ENDED questions
ACTIVITIES OF DAILY LIVING questions (ADLs)
Additional questions such as medicine, future surgeries, other HCP, support, stress level
Approximately 5-8 minutes
LMNOPQRSTU
location
mechanism –> how happened?
nature –> timing
onset
Pain –> level? 1-10?
Q –> quality of pain
Refer to another location
Systematic –>underlying conditions esp ask if nothing was stated for intake form
timing –> which times of day pain?
Underlying factors? –> other related symptoms?
L
location
MOT
mechanism, onset, timing
NPQR
pain, nature, quality, refer
SU
systemic, underlying?
grouping functionally
l mot npqr su
.
other questions
Other questions:
What makes it better? Heating pad, massage, stretching
What makes it worse? Ergonomics, poor self care, poor posture
Are your activities of daily living affected? Unable to do something ie. Brushing teeth, putting clothes on, shoulder checking when driving, carrying backpack
Medicine: When was the last time you had taken your medicine?
functional limitation
Functional Limitation
A normal ADL that is limited by muscular or connective tissue conditions
Reflective Listening
Reflective Listening
A method with which you reiterate the guest’s words to convey your comprehension or to clarify a misunderstanding.
Treatment Goal
Treatment Goal
A specific goal that is determined after therapeutic massage treatment to clarify progress toward restoring functional limitations
4 quadrants questions
1) Lifestyle Questions
(age, gender, activity level, occupation, fitness, etc)
2) Complaint/Pain Based Questions
(intensity, duration, pathway, makes it better/worse, any other pain I should know about?, etc.)
3) Affected Activities of Daily Living (ADL’s) Questions
(e.g. what can’t you do that you could do before? How are you compensating for this loss/pain/other? Etc)
4) Other
(medications, stress levels, other medical issues I should know about?, support system at home, etc)
ask about diet/exercise
ask about other HCP
ask about sleep
ask about ADL to determine posture
ask about orthotics
ask about job type (does it involve sitting?)
ask if seen other HCP (physio?)
ask about medications
special diet/exercise routine
ask
What brings you in today?
Occupation
Any diet or hydrotherapy restrictions?
Exercise regime - daily, weekly- no exercise.
General health. Other health concerns? Sleep patterns
Stress management regime / emotional management/ concerns
Are there any daily postures or positions that the guest holds for extended periods of time
Do you currently have a family health care provider – naturopath, osteopath, chiropractor, MD etc
Health Conditions
Injuries, Car Accidents (MVA’s) and Surgeries
Age Considerations
.
FIDDO
frequency
intensity
description
duration
onset
observe
breathing, speech, movements, comprehension, hygiene, etc
when does observation begin?
when therapist first sees patient (reception)
watch for…
Walking aids
Sitting or standing posture
Facial expression
General demeanor of patient
General health and cleanliness
after greeting in reception, watch for…
Gait patterns or patterns of compensation - walking with a limp, favoring one leg etc.
Breathing patterns
Pace of walking
Observe the shoes for wear patterns (overpronated/oversupinated gait)
Observe how the clothes fall on the person
in the treatment room, observe …
Ability to respond to questions
Tone of voice
Ability to focus and concentrate
Ease of providing information
Co-operation of the patient
Does the patient respond better to open or closed-ended questions
soft eye vs hard eye observation
Soft eye: Comes with practice. You would observe your patient’s tissue/posture through clothes or no clothes. This is observed in 4 views of the patient. You are not palpating them.
Hard eye: Preferably your patient would be in shorts and tank tops/sports bra. You would observe their posture and apply palpation. This is also observing in 4 views of the patient. Note: this is separate from palpation assessment which we will learn in next class
COMBINE BOTH IN SAME OBSERVATION EXERCISE
informed consent for observation
After History intake, you verbalize the informed consent for Observation
Depending on the nature of the complaint and the affected area the patient may be required to dress down to a comfortable level so the therapist can see the area.
Provide a brief summary about the assessment for observation.
Pain Scale
Do you have any questions?
Do I have your consent?
posture assessment, informed consent, e.g.
Hi Jane. To better understand about your (chief complaint) I’d like to have a look at your posture to see if maybe that could have something to do with your (complaint).
Did you bring shorts and tank top?
No, that’s okay, would you be okay to roll up your t-shirt sleeves, pants leg etc…?
I will be observing your posture in four directions to see how your chief complaint is affecting your posture or vice versa. After that, we can create a treatment plan that will be most beneficial for you and your (complaint)
postural scan
KNEES- Do the patella’s look level, Are the knees pointed in or out, compare the contours of the muscles around the knee
WRIST – What’s their position in relations to the elbow and forearm
SHOULDERS & UPPER EXTREMITY - observe the shoulders are they level, anterior or posterior to each other, the contours of the deltoids
ANKLES & FEET- Are the feet flat or raised, What’s the position and health of the toes
HIPS –observe for Level, Rotations, Contours
ELBOWS – Do they have the same degree of ‘valgus’, what’s the distance between the sides of the body and the elbows
HEAD - observe the head in relation to the rest of the body is it tilted, rotated, protracted, retracted, flexed, Extended
landmarks for sagittal plane alignment
between ankles/heels
between lower limbs
between spin, sacrum, sternum, skull etc
plumb line = symmetrical right/left
landmarks for coronal plane alignment
external auditory meatus
posterior to top of coronal suture
through dens of C2
midway through GH joint – or acromion
bodies of lumbar vert
sacral promontory
slightly posterior to AF jt
slightly anterior to TibioFemoral jt
slightly anterior to lateral malleolus
through calcaneocuboidal jt
