The Evaluation Process Pt. 1 Flashcards
4 parts of the evaluation process:
- recognition
- evaluation
- rehabilitation
- re-evaluation
_____ is the foundation of rehabilitation.
evaluation
2 things to determine in the evaluation process:
- a client’s chief complaint (CC)
- a client’s needs
The evaluation must be…
- systematic
- valid & reliable
- reproducible
Common _______ _______ techniques is useful in helping the examiner to solve a problem.
assessment recording
Recognize consists of:
- identify the physical basis for the symptoms that have caused the client’s pain or limited function/abilities
- to fully and clearly understand the client’s problem
Evaluate consists of:
accurately diagnose or gather an index of suspicion (IOS)
When determining rehabilitation plan, consider…
- severity
- irritability
- nature
- stage of injury
Re-evaluation consists of:
monitor progress at every visit
3 types of evaluations:
- pre-participation physical evaluation
- primary and secondary survey
- health care provider notes and evaluations
Pre-participation physical evaluations include:
- medicals for sport
- examination for MV operators
Primary and secondary survey includes:
HOPS (for first aider or first responder, done at time of injury) (History, Observation, Palpation)
Health care provider notes and evaluations includes:
- in clinic involving detailed history, assessment, and rehab notes
- SOAP (MSK)
- progress notes
- mental health assessment
- pain assessment
- psychological assessments
Documentation must be _____, _____ and _____.
- clear
- concise
- accurate
Common assessment recording technique:
medical records
Why are medical records helpful?
- legal reasons
- for insurance, for third party billing
Challenges of documentation:
- cumbersome and time consuming
- becoming proficient
- generate accurate records (inter, intra evaluator reliability)
4 keys to successful evaltation:
- sequential approach (thorough)
- systematic approach
- reproducible
- correct diagnosis
Why generate differential diagnosis?
- even if the diagnosis is obvious, use valuable information to decrease assumptions
- asking “what else could it be?”
- treatment plans vary depending on proper diagnosis
SOAP is a _____, _____, _____ and ______ evaluation process.
- systematic
- sequential
- developing
- differential
SOAP stands for:
- subjective
- objective
- assessment
- plan
SOAP is an _____ ____ technique and a method of _____.
- assessment recording
- documentation
Subjective (of SOAP) includes:
- understanding the client
- understand the demands or stresses, training schedules, functional requirements
- allows patient to explain in their own words the CC
- primary history info of CC
- perceptions: severity, pain, MOI
- demographics
- level of functional activity
Objective (of SOAP) includes:
- the evaluator’s findings
- findings that are observable and measurable
- observation (looking for)
- ROM
- palpation
- tests
- functional ability
Assessment (of SOAP) includes:
- the evaluator’s impression of the injury
- develops a probable impression of problem, including site of injury, structure involved, and severity rating
Plan (of SOAP) includes:
- the treatment plan
- can include: first aid, referral, treatment, rehab
- goals (short and long term)
3 parts of subjective assessment:
- injury history
- personal history
- sport/activity history
In the subjective assessment, we establish …
- the patient’s problem or CC
- a probable impression of the injury (site, structure, severity)
- comfort and trust through sequential dialogue
Subjective assessment requires…
effective and efficient communication techniques
The medical history is actually a story of the individual, where we are the journalist and are meant to…
edit and organize the patient’s spontaneous report into a formal, organized presentation
7 parts of part 1 (injury history):
- CC
- MOI
- sounds and sensations
- at the time of onset
- pain
- management (treatment) to date
- past medical history = previous injuries
3 parts of chief complaint (CC):
- client’s impression of the problem
- date of injury (DOI)
- location of the injury