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PTRS 745 Exam 1 > Examination and Assessment > Flashcards

Flashcards in Examination and Assessment Deck (61)
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1

Q: What are the parts of the SOAP note?

Subjective, Objective, Assessment and Prognosis, Plan of Care

2

Term: Collecting information from patients or responsible parties

Subjective examination

3

Q: What percent of the information you need comes from the subjective examination?

80-90%

4

Term: includes tests and measures

Objective examination

5

Term: identifies the relationship between the findings of the subjective and objective evaluation

Clinical judgement

6

Q: What part of the SOAP note contains reported symptoms?

Subjective

7

Q: What part of the SOAP note contains information on function?

Objective

8

Q: For what part of the SOAP note would you use clinical judgement?

Assessment or evaluation

9

Q:Our clinical judgment allows us to raise "________ ___________"

working, hypotheses

10

Q: During what part of the SOAP note is the diagnosis determined?

Assessment or evaluation

11

Term: combination of symptoms and signs that determine a particular condition.

Clinical syndrome

12

Term: related to the pt's functional ability, reported by the pt., and/or detected during the objective exam

Problem

13

Term: conditions that may change with the intervention

Problem

14

Term: predicting the pt's recovery

Prognosis

15

T/F: The diagnosis, problem, and prognosis all fall under the P portion of the SOAP note.

False, under A (assessment)

16

Term: reversing impairments

Remediation

17

Term: changes in the environment and tasks

Compensation or adaptation

18

Term: management of anticipated problem

Prevention

19

Q: Define the acronym SINSS

Severity, irritability, nature, stage, stability

20

Q: What is SINSS used for?

The base for the assessment

21

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

22

Q: What are important non-verbal communication skills to have during an examination? (2)

1. eye contact 2. body language

23

Content: SE - Patient Profile (5)

1. Age

2. Occupation

3. Current daily activity level

4. Recreation/hobbies

5. Psychosocial factors

24

Content: SE (6)

1. Pt. profile

2. Chief complaint

3. Body chart

4. Behavior of symptoms

5. History

6. Pt. goal

25

Content: Chief complaint (7)

1. Pain

2. Stiffness

3. Stability

4. Sensation of instability

5. Weakness

6. Loss of function

7. Surgery/trauma/immbolization

26

T/F: The least stable joint is the knee.

False: Shoulder

27

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

First hypotheses

28

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

29

Content: Pain sensations (2)

1. Nociceptive

2. Peripheral nervous system

30

Content: Types of nociceptive pain (3)

1. visceral - diffuse and difficult to locate

2. Deep somatic

3. Superficial somatic