Subjective assessment

Question 1

What are three key things that should generally be recorded

Answer 1

Consent recorded (check box complete)
NOK should be recorded
People present during the session’s full name should be recorded

Question 2

In an initial assessment what should be asked for history of presenting condition?

Answer 2

Onset of symptoms
Duration of symptoms
change in symptoms

Question 3

What should be asked for the body chart / presenting condition in an initial assessment

Answer 3

Presenting condition and pain sites should be identified
24hr pattern
Presence and description of neurological symptoms
Aggravating and easing factors
Subjective or patient recorded outcome measures

Question 4

Past medical history in initial assessment

Answer 4

Documentation of current and relevant past medical history
Current and relevant past medication
Documentation of screening for red flags and appropriate safety netting advice
Results of any recent and relevant investigations

Question 5

Social history in initial assessment

Answer 5

social, family, lifestyle and hobbies documented
occupation documented
work status
- normal duties
- restricted duties
- reduced hours
- etc

Question 6

Expectations. beliefs and goals

Answer 6

Patients beliefs are documented
Expectations documented
goals documented

Question 7

What are key subjective elements for subjective outcome measure

Answer 7

r/w subjective outcome measures
clinical and objective outcome measures
overall response to treatment progression of symptoms documented
evidence of a clinical reasoning process
Treatment plan is adapted based on symptom response
presence of any adverse or unexpected effects to treatments are reported