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?
