clinical assessment Flashcards
soap
SUBJECTIVE
What guests say about their condition
Their perception of the condition since the last treatment
OBJECTIVE
Obvious differences you notice before, during and after the massage
ACTIONS AND ANALYSIS
Which techniques or modalities were used
Which areas were the focus of treatment
Results of the current massage session
Prioritized functional limitations
Long and short term goals
PLAN
Plan for future massage treatments
Techniques to use or avoid, duration and frequency of future sessions
Self-care recommendations
Any specific products needed
Bath Salts, Thera-bands, Wobbleboards etc.
Referrals to other health care practitioners
DAR
DATA
Combined Subjective and Objective information
Observation, Palpation, Movement Assessments
More condensed and brief then SOAP charting
ACTION
Similar to SOAP charting except more condensed and shorter
RESULT
What is the final outcome of the treatment session
Plan for future sessions
Similar to “PLAN” in SOAP charting but more condensed
pain tension cycle
What happens with stress?
Stress is the physical reaction you have to a stressor.
• A stressor is anything that you perceive or feel causes stress.
Stressors may be from our environment – eg. Conditions on the worksite, loud noises, demanding schedules etc.
They may be from our own bodies – eg. Physical illness
They may be from our own perceptions of things – eg. Being stressed.
Some responses can add to the stress and become stressors –eg. Alcohol consumed/drugs to relieve stress
Intake Form
A form that documents the guests contact information, health history, or informed consent for care
Confidentiality
Information that is to be kept private unless the guest expressly permits you to share it
massage treatment record
The document containing your subjective and objective regarding the guest’s condition as well as the results of the treatment session and plans for future sessions
ADL activity of daily living
Normal activities performed during an average day
functional limitation
A normal ADL that is limited by muscular or connective tissue conditions
treatment goal
A specific goal that is determined after therapeutic massage treatment to clarify progress toward restoring functional limitations
case history question 1-4
1) Lifestyle Questions
(age, gender, activity level, occupation, fitness, etc)
2) Pain/Complaint 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)
orthopedic format of assessment
HOPMNRS History Observation Palpation Movement Neurological Referred/Radiating Pain Special Tests
reflective listening
A method with which you reiterate the guest’s words to convey your comprehension or to clarify a misunderstanding
rapport
A mutual trust in a relationship
treatment goal
A specific goal that is determined after therapeutic massage treatment to clarify progress toward restoring functional limitations
THE 4 QUADRANTS ARE:
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
PAIN COMPLAINT QUESTIONS
Has this happened in the past?
Determine ‘when’ did the complaint started – referred to as the ‘onset’ of the problem?
Was trauma involved, or it just started, or is it due to degeneration of the joints, age related or previous injury
Do you take any medications?
Any family with similar complaints?
Have you seen a physician for this concern, or any other practitioner?
What was the results of the visit
How has this condition affected their ADL
Was there any specific ‘mechanism of injury’ - describe it
Is there any pain involved
locate the side of pain with FIDDO
Frequency Intensity Description Duration Onset
pain related questions
AREA where does it bother you
NATURE describe what it feels like
BEHAVIOUR does it come and go come at night or morning certain movements hurt more?
DURATION is it constant or do you only feel it when you’re sitting or walking
FREQUENCY every hour? 20 minutes day?
pain pressure scale
Used for Quantifying Pain
Excellent Resource for monitoring progress
Pressure Scale used for Manual Skills Purposes
pain based questions
Any activity makes in worse? Activity that makes it better? Loss of ROM?
Any other symptoms such as numbness and tingling
Is it getting worse or better with time?
Are you using any pain medications?
On a pain scale from 1-10 – 10 is the worse pain ever experienced - where on that scale is the current pain?
an RMT’s goal is to get to
100% pain free functional movement or as close to it
affected activities of daily living questions
Function: Basic Personal ADL’s
(e.g. what can’t you do that you could do before? How are you compensating for this loss/pain/other? Etc)
What Daily Actions have been affected by this condition?
Bed Activities – moving in bed, managing pillows/blankets, reaching for objects (water/night lights), sitting up
Hygiene Activities - Brushing Hair/Teeth, Bathing and Showering, Washing, Toileting, Shaving, Putting On Makeup
cont
Eating Activities – using utensils, cutting meat(or tofu), managing a glass and cup
Dressing Activities – putting on clothes, tying laces, putting on socks and shoes, fastening a bra, putting a shirt over head.
Transfer Activities – Bed to chair, sit to stand, getting into car, getting on bus
Walking Activities – Level and uneven surfaces, curbs and stairs, opening doors, walking and carrying items, distance and velocity, assistive devices, gait deviations
short term goals
1-2 weeks
each stg should support ltg
