Transcript Chapter 5

Chapter 5
The Patient/Client
Management Format:
History
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The examination section has 3 subsections:
History
 Systems Review
 Tests & Measures
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History
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Identifying Information
Current Conditions/Chief Complaints
Social History
Employment Status
Living Environment
General Health Status
Social/Health Habits
Family Health History
 Patient’s Medical/Surgical History
 Functional Status/Activity Level
 Medications
 Growth and Development
 Other Clinical Tests
* Not every category may be used with every
patient.
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Abbreviations & Medical
Terminology
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Appropriate abbreviations and terminology is
expected
Correct spelling
Concise
Do not need to use full sentences
Do not need to identify source of information,
unless conflicting information is given
Organization
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Headings or subcategories may be used
Example:
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Social History: Lives alone. Employment: Works full
time inside of home. General Health Status: Rates
general health as fair.
Chapter 6
The Patient/Client
Management Format:
Writing Systems Review
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Information in this section is often listed as not
impaired or impaired
Specific descriptions and measurements are
written in Tests & Measures section
Categories Used to Report the
Systems Review
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Cardiovascular/Pulmonary
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Integumentary
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Skin color, texture, disruption
Musculoskeletal
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Heart Rate, Blood Pressure, Edema
Symmetry, range of motion, strength
Neuromuscular
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Gait, balance, motor control
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Communication, Affect, Cognition, and
Learning Style
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Emotions, vision, hearing inabilities, language
barriers
Chapter 7
The Patient/Client
Management Format:
Documenting Tests &
Measures
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Tests & Measures are measurable or observable
Can be repeated during treatment to evaluate
progress
Categories
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Based on profession and types of tests &
measures performed
Examples:
Ambulation
 Transfers
 Balance
 Range of Motion (ROM)
 Strength
 Sensation
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Methods of Recording Data From
Tests & Measures
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Complete sentences are not necessary
Tables, charts, flow sheets
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Include patient’s name and date
Chapter 8
The SOAP Note: Stating
the Problem
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SOAP notes use the same information as the
Patient/Client Management Format, but
organizes according to the source of information
instead of the type of information
The problem is often stated before the SOAP
note begins
The problem is the patient’s chief complaint or
diagnosis
Chapter 9
The SOAP Note: Writing
Subjective (S)
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The Athletic Trainer states the information
received from the patient that is relevant to the
patient’s present condition
Similar to the History section of the
Patient/Client Management Format
Categorizing Items as Subjective
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Current conditions/chief complaint
Functional status/activity level
Social history
Employment status
Living environment
General health status
Social/health habits
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Family health history
Medical/Surgical history
Medications
Growth & Development
Other clinical tests
Response to treatment interventions
Patient’s goals
Anything else
Use of the Term Patient
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Use “patient” the first time but do not repeat
with every sentence
Abbreviations and Medical
Terminology
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

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Appropriate abbreviations and terminology is
expected
Correct spelling
Concise
Do not need to use full sentences
Do not need to identify source of information,
unless conflicting information is given
Organization
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Headings or subcategories may be used
Do not include information or subcategories in
the note just for the sake of inclusion
Verbs
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Use of verbs indicates that the statements are
subjective
Examples:
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States, describes, denies, indicates
Quoting the Patient Verbatim
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Use direct quotes to show confusion, memory
loss or denial, or to describe pain
Chapter 10
The SOAP Note: Writing
Objective (O)
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The Objective section includes result of test and
measurements and the Athletic Trainer’s
observations
Data is measurable or observable and can be
repeated during treatment to evaluate progress
Categories
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Athletic Trainer’s inspection and observation
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Palpations
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Deformity, discoloration, swelling, gait, how athlete
carries themselves
Bony landmarks, soft tissue
Special Tests
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Special tests, range of motion, strength, balance,
sensation
HIPS/HOPS Method
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History (S)
Inspection/Observation (O)
Palpation (O)
Special Tests (O)