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Clinical Assessment Protocol > Quiz 1: Clinical Assesment > Flashcards

Quiz 1: Clinical Assesment Flashcards

1
Q

Assessment must be _____, ______,_____

A

assessment must be organized, comprehensive and reproducable

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2
Q

Why do you need to use clinical assessment protocol?

A

to know which technique to employ or area to focus on

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3
Q

As a therapist, how should you gather information?

A
  • Audio: What the patient tells you
  • Visual: What the therapist observes
  • Palpation: what is the quality of tissue or structure?
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4
Q

To be efficient during clinical assessment you need to:

A
  • Listen: what patient says, and whats in their history
  • Watch: patients body, movement, and what palpation is telling you
  • create a goal: deduce area of concern, possible causes, and what changes the therapist wishes to create
  • reassess: to know the markers of completing a goal
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5
Q

During clinic assessment how should you approach decision making (in order)?

A
  1. Case history form
  2. Interview form
  3. Initial scan exam form
  4. Joint assessment
  5. postural assessment
  6. gait assessment
  7. treatment goals and treatment modalities
  8. remedial exercise
  9. management plan
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6
Q

What is HOPMNRS?

A 
History
Observation
Palpation
Movement
Neurological
Referred pain
Special tests
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7
Q

What are the 4 T’s of palpation?

A

tone
texture
temperature
tenderenss

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8
Q

What is dermatome?

A

area of skin that is mainly supplied by a singe spinal nerve

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9
Q

What is a myotome?

A

muscle served by single nerve route. motor equivalent of dermatome

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10
Q

What is the ABCDE of informed consent for massage?

A 
Area
Benefits
Cautions
Draping
Empowerment/Enquire
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11
Q

What does informed consent for massage entail?

A

ABCDE, description of treatment, inform about any risks, benefits, contraindication and/or possible complications, inform treatment can stop at any time or modified, ask for clear YES OR NO

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12
Q

True or false: once you get consent the patient cant change their mind

A

false: consent can be removed at anytime

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13
Q

What is confidentiality?

A

duty to keep personal information private

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14
Q

What is privacy?

A

right of a person to decide what about them may be collected, used, and shared with others

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15
Q

What is security

A

protect availability, integrity, and confidentiality of personal information

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16
Q

Describe FOIPPA

A

Freedom of information and protection of privacy act:

  • BC law provides information and privacy rights concerning information that is colected and controlled by public bodies
  • Allows ppl to access their personal info
  • protects their privacy by limiting the collection, use and sharing of personal info
  • ensures individuals are able to access information held by public bodies

BASICALLY DONT SHARE PERSONAL INFO

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17
Q

What is personal information?

A

any recorded info that identifies that person

18
Q

Give some examples of breaches of confidentiality

A
  • storing credit card info
  • removing patient info from clinical setting
  • accessing info not related to ur duties
  • discussing patient info where others can hear
  • carrying/delivering info in a way others can see
  • discussing patient cases with other ppl with identifying info
19
Q

If a patients intake form is dated more than a year ago what do you do?

A

update it. indicate it as been edited, post new date and get client to initial it. if possible update in different colour

20
Q

When is the intake form receieved?

A

before receiving patient

21
Q

When walking your patient to the treatment room, what should you look out for?

A
  • functional movement
  • body type
  • gait
  • emotional attitude
  • footwear
  • facial expression
  • general ease of self
22
Q

Give some examples of red flags: cancer

A
  • persistent pain at night
  • constant pain anywhere in body
  • unexplained weigh-loss
  • loss of appetite
  • unusual lumps or growths
  • unwarranted fatigue
  • sweating at night
23
Q

Give some examples of cardiovascular red flags

A
  • shortness of breath
  • dizziness
  • pain or feeling of heaviness in chest
  • pulsating pain anywhere in body
  • constant and severe pain in lower leg
  • discoloured or painful feet
  • swelling
24
Q

give examples of GI or GU red flags

A

frequent or severe abdominal pain
frequent or severe heartburn or indigestion
frequent nausea or vomitting
change in or problems with bowels and or bladder
unusual menstrual irregularities

25
Q

give some examples of neurological red flags

A

changes in breathing

frequent or severe headaches with no history of injury

problems with swallowing or changes in speech

problems with balance, coordination or falling

faint spells

sudden weakness

26
Q

give some examples of misc. red flags

A

fever or night sweats
recent severe emotional disturbances
swelling or redness in any joint with no history of injury
pregnancy

27
Q

give examples of yellow signs

A
  • abnormal signs and symptoms
  • bilateral symptoms
  • symptoms peripheralizing
  • neurological symptoms
  • multiple nerve root involvement
  • abnormal sensation patterns
  • saddle anesthesia
  • upper motor neuron symptoms and signs
  • fainting
  • drop attacks
  • vertigo
  • autonomic nervous system symptoms
  • progessive weakness
  • progressive gait disturbancs
  • multiple inflamed joints
  • psychosocial stresses
  • circulatory or skin changes
28
Q

True or false: you should always review patient intake form

A

true

29
Q

What are important areas to note on the intake form?

A 
primary complaint
past injuries
medications
their personal opinion of stress and health
underlying condition
30
Q

For in initial interview what is LIDFOAR

A 
Location
Intensity
Duration
Frequency
Onset
Aggrivating
Relieving
31
Q

What are the steps to the initial interview (in order)

A
  1. consent
  2. review intake form
  3. gathered relevant information
  4. ask for consent to observe
  5. ask about orthotics
32
Q

What are the cardinal signs of pathology? (SHARP)?

A 
swelling
heat
a loss of function
redness
pain
33
Q

Do you have to keep records for every patient? If so, why?

A

yes, record keeping must be done for each client

for client safety and therapist records

34
Q

Keeping charts are documentation of what?

A

assessment
treatment
outcomes

35
Q

What is the charting format: SOAP

A

Subjective
Objective
Action
Plan

36
Q

What charting format is: DAR

A

Data
Action
Responnse

37
Q

What colour pen should you use for charting?

A

blue or black

38
Q

What are the 4 T’s of palpation

A

Tenderness
Texture
Temperature
Tone

39
Q

When palpating what side should you palpate first?

A

unaffected side first then compare to the affected side

40
Q

Can you do palpation during observation?

A

Yes, it is recommended to save time

41
Q

What do you do if you make a mistake on your chart?

A

Any mistakes cross out with a single line and initial it

42
Q

What do you do if a patient doesn’t speak english?

A

translator
use visual communication
use visual pain scale
it may not be safe to treat

Clinical Assessment Protocol (1 decks)

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