Clinical Assessment final Flashcards
the 7 (or 8) steps
HOPMNRS (or hopgmnrs)
History
observation
palpation
movement
neurological
referred
special tests
(gait)
Schedule “D” of the CMTBC bylaws
A Registrant must
1) perform a comprehensive assessment based on history, observation, palpation, movement, neurology, referred sensation and special tests as relevant,
2) formulate a treatment plan, and
3) monitor vital signs as relevant (pulse, blood pressure, respiration rate, temperature).
4 vital signs
Body temperature.
Pulse rate.
Respiration rate (rate of breathing)
Blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the vital signs.)
Also Schedule “D” of CMTBC bylaws
Registrant must
1) design and implement a management and treatment plan based on clinical findings, and
2) design and coach a home care program and activities of daily living.
Why do we chart? (Schedule “E” of CMTBC bylaws)
1) It is a requirement from CMTBC Bylaw.
Schedule “E” of the CMTBC Bylaws.
2) Protection of Personal Information
3) 2A Registrant must protect and maintain the confidentiality of Personal Information and take all reasonable measures to ensure that the collection, use, access, disclosure, care and disposal of Personal Information occur in accordance with thePersonal Information Protection Act, and any other legal requirements
What needs to be included in our documentation for each patient?
a clinical record for each patient (the “Health Care Record”) containing:
1) patient identifying information as provided by the patient, including the patient’s full name, gender, and date of birth,
2) the patient’s current address and telephone number, as of the date of their last attendance,
3) the name of the Registrant who rendered the treatment to the patient,
what else to include in charting/documentation
1) referring Registrant or Licensed Practitioner,
2) any medical history provided by the patient, as of the date of their last attendance,
3) any reports received from or sent to other Registrants, Licensed Practitioners, and insurance providers with respect to the patient,
What else to include?
all dates of attendance
why the patient came to see the Registrant
what the Registrant learned from both the patient’s current medical history and the assessment
information relevant to the patient’s condition,
clinical impressions, and
clinical findings and periodic reassessment findings,
what else?
any treatment plan, including any revisions made thereto,
treatment provided and the patient’s response to such treatment,
any follow-up plan, and
any recommendation or instructions for patient self-care related to the patient’s condition, and
what else must be done for documentation?
written in an official language of Canada, and
in paper form, written legibly in ink or typed, or
in electronic form, compliant with the policies and guidelines of the College with respect to the creation, maintenance, security, disposition and recovery of electronic medical records,
SOAP
Subjective
Objective
Action
Plan
subjective
patient’s chief compaint
their perception of their complaint
SYMPTOMS subjective
SIGNS objective
Objective
RMT’s perception via
OPMNRS (as well as gait)
Action
In Documentation –> What did the massage therapist do in the session?
1) what position was client in? (prone, supine, semi-reclined) etc
2) what modalities/techniques were used?
3) reassessment
Plan
document the following:
1) provided homecare (stretch, strength, hydro, ADL with FIDS)
2) What techniques or modalities were effective or ineffective?
3) Recommendations for other HCP
