Q: What are the parts of the SOAP note?
Subjective, Objective, Assessment and Prognosis, Plan of Care
Term: Collecting information from patients or responsible parties
Q: What percent of the information you need comes from the subjective examination?
Term: includes tests and measures
Term: identifies the relationship between the findings of the subjective and objective evaluation
Q: What part of the SOAP note contains reported symptoms?
Q: What part of the SOAP note contains information on function?
Q: For what part of the SOAP note would you use clinical judgement?
Assessment or evaluation
Q:Our clinical judgment allows us to raise "________ ___________"
Q: During what part of the SOAP note is the diagnosis determined?
Assessment or evaluation
Term: combination of symptoms and signs that determine a particular condition.
Term: related to the pt's functional ability, reported by the pt., and/or detected during the objective exam
Term: conditions that may change with the intervention
Term: predicting the pt's recovery
T/F: The diagnosis, problem, and prognosis all fall under the P portion of the SOAP note.
False, under A (assessment)
Term: reversing impairments
Term: changes in the environment and tasks
Compensation or adaptation
Term: management of anticipated problem
Q: Define the acronym SINSS
Severity, irritability, nature, stage, stability
Q: What is SINSS used for?
The base for the assessment
Q: What are important verbal communication skills to have during an examination? (5)
1. ask one question at a time 2. speak slowly 3. avoid medical jargon 4. make no assumptions 5. belief and empathy
Q: What are important non-verbal communication skills to have during an examination? (2)
1. eye contact 2. body language
Content: SE - Patient Profile (5)
3. Current daily activity level
5. Psychosocial factors
Content: SE (6)
1. Pt. profile
2. Chief complaint
3. Body chart
4. Behavior of symptoms
6. Pt. goal
Content: Chief complaint (7)
4. Sensation of instability
6. Loss of function
T/F: The least stable joint is the knee.
Content: consider the following 1. Movement dysfunction 2. Neurophysiological symptoms 3. Contraindications 4. Illness experience and behavior 5. Treatment objectives 6. Prognosis - short and long term effects
Content: Things to put on the body chart (5)
1. Location/target area
2. Description of pain
3. Clear other (pain free) areas
4. Assign each pain (P1, P2, etc)
5. Establish a relationship between symptoms
Content: Pain sensations (2)
2. Peripheral nervous system
Content: Types of nociceptive pain (3)
1. visceral - diffuse and difficult to locate
2. Deep somatic
3. Superficial somatic