Health History and Charting Flashcards
What is assessment?
The collection and interpretation of information provided by the patient, the patient’s consent, and the referring medical professionals, as well as the information gathered by the massage practitioner
Assessment is a learned skill
Incorporating this into a massage session enhances the quality of the treatment given by the massage therapist
Massage therapists are NOT allowed/equipped to diagnose any specific medical condition
Safe and effective Q
Assessment is always done bilaterally and unaffected side first to compare sides
The assessment process can be simple, ruling out contraindications for a one-time session (ex. Day spa, resort, etc) or as comprehensive as determining a patient’s needs for therapeutic massage provided as a health care component (ex. Part of a rehabilitation or pain management program)
The treatment plan can vary from being simple (ex. a present for a birthday) to complex (ex. The use of massage for stroke rehabilitation)
Always ask yourself the question, “what information do I need to develop a safe, effective (Q) massage therapy treatment plan for this patient?”
Assessment is treatment
Musculoskeletal Assessment Components
Patient History
Observation and Palpation
Examination of Movement (ROM)
Muscle Testing
Special Testing
Reflexes and Cutaneous Distribution
Joint Play Movements
Diagnostic Imaging
Documentation
Accurate and comprehensive ( can be tricky, because they may not want to tell us everything) documentation has become increasingly important for massage therapists
Problem-oriented medical records were developed in the 1960’s by Dr. Lawrence Weed
This type of documentation uses a critical thinking process to collect information and organize it according to a system known as the SOAP format
SOAP stands for subjective, objective, assessment/analysis and plan
Interview/Patient History
A complete history should be taken and documented to ensure reliability
This requires effective and efficient communication and the ability to develop a good rapport with the patient
It is important to speak at a level and use terms that the patient will understand, take the time to listen, be empathetic(be able to put your self in their shoes), interested, caring and professional
Repetition will help the therapist to become familiar with the characteristic history of patient’s complaints so that any deviation is noticed immediately
Even if the condition/disorder is obvious, the history provides valuable information about the condition/disorder
Purpose of the Interview
The purpose of the interview is to help the patient communicate their health history and to understand the goal for the massage
Information during an interview is gathered, NOT interpreted. Interpretation comes once all of the information is gathered, which can take several sessions
It is important to use words that the patient can understand. Professionalism is important, but using medical terminology should not be used to confuse the patient or create misunderstanding
Asking for clarification enhances knowledge and understanding of the information obtained
A health history intake form provides a framework for obtaining necessary and important information during the interview
Open-ended questions encourage conversation (ex. How does your leg feel?) This requires the patient to give more detail when answering
Closed-ended questions should be avoided (ex. Does your leg hurt in the morning?)
It is important as the therapist to really listen when the patient is responding, it is hard to think or write while listening
The conversation during an interview should proceed slowly and the patient should never feel rushed
Try not to interrupt the patient as then often forget what they were telling you
The therapist should restate the information the patient provides so that they can correct any information that wasn’t right
Keep an open mind
Pertinent Information/Questions to Seek Answers To
Age/sex/gender
Occupation (sometimes they don’t want to let us know, we can ask what position do they do at work)
Chief complaint
Mechanism of injury
Onset slow or sudden?
Symptoms
Where was/is the pain?
What movements/activities cause pain?
How long has the problem existed for?
Has the condition occurred before?
Any other injuries?
What is the intensity, duration and/or frequency of the pain or other symptoms?
Does the pain change with rest or activity?
What is the quality of pain? sharp, tingling,…
Is there any abnormal sensations?
Is there any abnormalities with the joint(s)?
Has the patient experiences any bilateral spinal cord symptoms?
Any changes in colour of the limb(s)?
Has the patient experienced any life or economic stresses? Can make pain and symptoms worse
Does the patient have any chronic or serious systemic illnesses or adverse social habits? smoking
Is there any family or developmental history that may be related?
Any diagnostic imaging done?
Any medications taken?
History of surgery or illnesses?
Mneumonic for interview: LIDFOAAR, OLDChARTS
L – location elbow
I - Intensity 1,2,3
D – duration how long ago
F – frequency how offen it happens
O – onset how does it happen
A - activities of daily living (ADL’s)
A – aggravating what makes it worse
R – relieving what makes it better
O – onset
L - location
D - duration
C - characteristics
A - alleviating/aggravating
R - radiating
T - temporal pattern/time
S - severity
There are others, ex. LOCQSMAT: Location, Onset, Chronology, Quality, Severity, Modifying factors, Additional symptoms, Treatment
Pain Questions
Where is the pain? Can you point to it(L)?
What is the pain scale 1-10(I)?
How long have you been experiencing it(D)?
How often do you feel them(F)?
How and when does it happen? Mechanism of injury(MOI)(O)
Does it affect any of you ADLs(activity of daily living)(A)?
What aggravates the pain(A)?
What relieves the pain(R)?
Are there any other symptoms associated with this condition?
Red and Yellow Flags in more in your book
Red Flags NO NO
Signs and symptoms that would indicate the problem is not a musculoskeletal one or a more serious problem that should be referred to an appropriate health care professional
Yellow Flags MAY BE
Signs and symptoms that indicate problems that may be more severe or may involve more than one area requiring a more extensive examination, or may relate to cautions and contraindications to treatment that may need to be considered
Pain Evaluation
The evaluation of pain is classically a subjective measurement
Pain assessment tools help patients describe their pain
Three examples of assessment instruments that focus on subjective outcomes are:
Pain scales (measure the intensity of pain)
Ex. numeric rating scale, visual analog scale, categorical scale, pain face scales
Pain drawings (measures the location and quality of pain)
Ex. generic human body forms representing all views of the body for patients to color in or draw their symptoms
McGill Pain Questionnaire (measures sensory and cognitive experience of pain)
Pain Scale 1-10 – General idea
1: Almost no pain or discomfort, may only be aware of pain when specifically focusing on it.
2: Very minor pain, like a light pinch. Noticeable but not disturbing.
3: Mild pain, similar to a small scratch or abrasion.
4: Mild to moderate pain. Noticeable and may cause slight discomfort during normal activities.
5: Moderate pain. Distracting and can affect concentration and daily tasks.
6: Moderately strong pain. Can impede regular activities and focus.
7: Strong pain that dominates senses and significantly limits ability to perform daily activities.
8: Intense pain. Physical activity is severely limited. Pain is often constant.
9: Excruciating pain, nearly unbearable. The client may be unable to speak or move comfortably.
10: Unimaginable, incapacitating pain. Emergency medical attention may be necessary.
Pain
Pain is subjective
Pain can be influenced by a patient’s emotional state, culture, past experiences, learned behaviours and motivation. Chronic pain in particular can be accompanied by depression and anxiety.
Severe pain-if the patient is unable to move in certain directions or hold a particular posture due to the intensity of pain or symptoms pain when you work
Irritable pain-if the symptoms or pain become progressively worse with movement or worsen the longer a position is held pain no matter what
Acute pain-new pain that is often severe, continuous and sometimes disabling. Acute injuries tend to be more irritable and often minimal activity will bring on symptoms. Usually acute pain is accompanied by anxiety.
Chronic pain-is usually more aggravating, is not as intense, has been experienced before and usually the patient knows how to deal with the pain. Usually chronic pain is associated with depression
Referred pain -tends to be felt deeply and its boundaries are not distinct and it radiates segmentally. May come from cutaneous, deeper somatic and visceral tissue. Occurs in tissue that is remote from the original lesion or injury bang on your hands then you feel the pain on your shoulders
Constant Pain-pain is always there, but varies in intensity. It suggests chemical irritation, tumors, or possibly visceral lesions
Peripheral vs Central Sensitization
Peripheral Sensitization
A local phenomenon that occurs when tissue has been damaged and inflammation occurs resulting in localized pain
Also known as primary hyperalgesia
Central Sensitization
A more central process involving the brain and spinal cord that occurs if the injury does not follow a normal healing pathway and becomes chronic
Also known as secondary hyperalgesia
Types of Pain
Bone pain
Tends to be deep, boring and localized
Vascular pain
Tends to be diffuse, aching and poorly localized and may be referred to other areas of the body
Muscle pain
Usually hard to localize, dull and achy and is often aggravated by injury and may be referred to other areas
Radicular Pain
Associated with nerve root compression. Sharp, shooting pain may be accompanied by other neurological signs such as paresthesia corresponding to a dermatome or muscle weakness
Cutaneous pain
From superficial tissue damage. Described as being sharp, bright, burning and well-localized
Deep somatic pain
From muscles, tendons, joints and periosteum. More diffuse than cutaneous pain, can refer to other areas of the body
Visceral pain
Arises from visceral distension or ischemia or strong, abnormal gastrointestinal contractions. Often diffuse like stomach pain
Documentation
S-subjective
O-objective
A-assessment
P-plan
S: Subjective information is the chief complaint (main problem) and history portion of the record
This information is collected from the patient and from previous records
Key goals that are quantified and qualified
Activities that are affected by the situation-often stated as what can no longer be done or what increase in performance is desired
O: Includes findings from the physical examination and the results of any tests
Significant physical assessment findings
Intervention modalities and locations used
General approach used, such as general massage focus, CT focus, Swedish massage focus, etc
If not recorded elsewhere, the duration of the session
