Intro to Charting Flashcards
Define Critical Thinking
- Reasonable reflective thinking
- To engage in an activity with reflective skepticism
- Purpose goal directed thinking
What is Clinical Reasoning
- Hypothesis –> Questions/Examinations/Testing
If refuted, new hypothesis - same examinations - Pattern recognition - could suggest a diagnosis
Define “Differential Diagnosis”
A process by which we use our clinical experience to identify or relate signs and symptoms to a ‘clinical disorder’
What two things need to happen before a treatment plan can be made
Critical Thinking
Clinical Reasoning
What is SOAP charting?
Subjective
Objective
Actions and Analysis
Plan
What does ‘Subjective’ refer to in SOAP charting
- Chief Complaint
- What guests say about their experience - pre, during, and post treatment
Ex pain
What does ‘Objective” refer to in SOAP charting
Obvious and measurable observances before, during, and after treatment
Ex Angles, Range of motion, Postural, Palpation assessments
What is ‘Actions and Analysis’ referring to in SOAP
Which treatments were done and what outcomes came from them
What does ‘Plan’ refer to in SOAP charting
Follow up from previous treatment Plan for current treatment Plan for future treatments Contraindications Self-care recommendations
When is SOAP charting used
ALL first-time patients
What is DAR charting
Data
Actions
Results
When is DAR charting used
With return patients
What does ‘Data’ refer to in DAR charting
S and O, from SOAP, combined (Subjective and Objective)
What does ‘Action’ refer to in DAR charting
Same as A from SOAP only more condensed
What does ‘Result’ refer to in DAR charting
Same as P from SOAP only more condensed
- Final outcome of treatment session
- Plan for future sessions
