Evaluation - 1 Flashcards
subjective
C.H.A.R.T.S
chief complaint
history
asymmetries
ROM
tissue characteristics
special tests
what does the AOPT use based on PT exam
decision trees
what kind of note do we use
SOAP note
what does a SOAP note create
a narrative
S –> SOAP
subjective
O –> SOAP
objective
A –> SOAP
assessment
P –> SOAP
plan
the SOAP note includes
more than exam findings
subjective includes
chief complaint
history
chief complaint
reason for seeking tx
pt’s own words
assess for red and yellow flags
history
determine health state
pt’s story
chief complaint –> SINSS
severity
irritability
nature
stage
stability
severity –> SINSS –> chief complaint
pt rating
limit to ADL
irritability –> SINSS –> chief complaint
amount and type of activities that aggravate/ease
nature –> SINSS –> chief complaint
characteristics of the pain, pathologies, pt experience
stage –> SINSS –> chief complaint
acute, subacute, chronic, acute on chronic
stability –> SINSS –> chief complaint
progression of current or past sxs
radiating
location
local v. diffuse
pain that increases w/ movement/position or decreases right away
mechanical, on-off pain, low irritability
AM pain and stiffness, improves w/ activity, aching as day goes on
chronic inflammation
effusion
resting pain and pain that is worse at beginning of activity
acute inflammation
pain that is unaffected by rest or activity
bone pain
serious pathology
pain that is worse at night
nerve entrapment?
serious pathology?
history of the onset
macrotrauma
microtrauma
slow or sudden
insidious
history –> health state
activities
participation
beliefs
history –> dz state
changes
beliefs
behaviors
history –> the journey
causative
contributory
history –> goals
theirs
possibilities
systems review
general demographics
living environments
PMH/PSH
general health
pharmacology
current condition
tests
family
work
social
