Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Semester 2 > clinical assessment > Flashcards

clinical assessment Flashcards

1
Q

why chart?

A

communication with other HCP

legal requirement

therapist self reflection

monitor progress in patient

database

guest records

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

indelible record consisting of … must be kept by registrant (CMT bylaws, Schedule D, standards of practise)

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

SOAP chart acronym

A

subjective
objective
action and analysis
plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

1) subjective (SOAP)

A

patient’s complaint

how patient describes own condition

their perception

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

2) objective (SOAP)

A

differences noticed by therapist

PGPM assessments:
postural assessment
gait assessment
palpation assessment
movement assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

3) Action/analysis (SOAP)

A

which techniques used?

which body part treated?

result of session?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

4) Plan (SOAP)

A

plan for future treatments

self-care routines – e.g. strengthening/stretching exercises

referral to other HCP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

DAR charting

A

Data
Action
Result

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

1) Data (DAR)

A

combined subjective/objective

observation, palpation, movement etc

more condensed/brief compared to SOAP charting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

2) Action (DAR)

A

similar to Action of SOAP

More condensed/brief compared to SOAP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

3) Result (DAR)

A

similar to PLAN in SOAP, but more condensed/brief

outcome of treatment?

plan for future session

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

PAIN TENSION CYCLE

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

chronic pain cycle

A

pain
immobilization
disability
self-esteem
depression
isolation/withdrawal
stress
muscle tension
pain
etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

how does body respond to stress?

A

breathing pattern
circulation
nervous system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

signs of stress

A

sleep
digestion
despair
fatigue
hostility
alcohol/drug use
danger/risk
TV
etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

HOPMNRS and Gait

A

history
observation
palpation
(gait)
movement
neurological
referred pattern
special tests (BP/pulse)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Scope of practice: diagnosis

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Schedule D, CMTBC bylaws — a patient must…

A

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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Schedule E, CMTBC bylaws – why do we chart?

A

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

20
Q

.

A

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

21
Q

additional info on intake sheet

A

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

22
Q

open vs closed ended questions

A

open ended = subjective info from patient

closed-ended = objective info from patient

23
Q

initial interview =

A

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

24
Q

LMNOPQRSTU

A

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?

25
Q

L
location

MOT
mechanism, onset, timing

NPQR
pain, nature, quality, refer

SU
systemic, underlying?

A

grouping functionally

26
Q

l mot npqr su

A

.

27
Q

other questions

A

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?

28
Q

functional limitation

A

Functional Limitation
A normal ADL that is limited by muscular or connective tissue conditions

29
Q

Reflective Listening

A

Reflective Listening

A method with which you reiterate the guest’s words to convey your comprehension or to clarify a misunderstanding.

30
Q

Treatment Goal

A

Treatment Goal
A specific goal that is determined after therapeutic massage treatment to clarify progress toward restoring functional limitations

31
Q

4 quadrants questions

A

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)

32
Q

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

A

special diet/exercise routine

33
Q

ask

A

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

34
Q

Health Conditions
Injuries, Car Accidents (MVA’s) and Surgeries
Age Considerations

A

.

35
Q

FIDDO

A

frequency
intensity
description
duration
onset

36
Q

observe

A

breathing, speech, movements, comprehension, hygiene, etc

37
Q

when does observation begin?

A

when therapist first sees patient (reception)

watch for…
Walking aids
Sitting or standing posture
Facial expression
General demeanor of patient
General health and cleanliness

38
Q

after greeting in reception, watch for…

A

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

39
Q

in the treatment room, observe …

A

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

40
Q

soft eye vs hard eye observation

A

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

41
Q

informed consent for observation

A

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?

42
Q

posture assessment, informed consent, e.g.

A

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)

43
Q

postural scan

A

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

44
Q

landmarks for sagittal plane alignment

A

between ankles/heels

between lower limbs

between spin, sacrum, sternum, skull etc

plumb line = symmetrical right/left

45
Q

landmarks for coronal plane alignment

A

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

Semester 2 (14 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions