Flashcards in Final Deck (23):
Which is a button and which is freeform:
Record active = button
Resting VAS = freeform
Where do you enter information not pertaining to the chief complaint?
What is the differential diagnosis?
list of potential diagnosis
What is a diagnostic study?
studies that go above and beyond what is done in the office (i.e. lab work, CT's, etc.)
What is a prognosis and how is it classified?
How you expect the patient to do
--(poor, fair, good, excellent)
What 4 forms are used with a new patient encounter?
-- Health questionnaire
-- History form
-- Post history critical thinking form
-- Post exam critical thinking worksheet
A basic physical exam includes what 3 things?
-- System exam relating to the complaint
-- comprehensive ortho-neurological exam
If you plan to adjust all areas of the spine, what needs to be done?
screening exam in all areas
--(i.e. SLR, Kemps, Bakody, etc.)
The process involved in starting a patient and working up to an adjustment includes what 6 things?
-- Diagnostic studies
Where should you wear your badge?
on collar or lapel
When is a clinic jacket required?
if not wearing clinic approved polo
What constitutes an exam in the clinic?
-- Outcome Assessment
What goes on a radiology requisition?
-- Clinical impression
-- Reason for taking Xray
-- Patient history
==== (is it gold standard, what to do if positive)
What are the parts of a SOAP note?
What info goes in the "S" for SOAP notes?
== What the patient tells you
What info goes in the "O" for SOAP notes?
-- Measurable and Observable data
== What you found
What info goes in the "A" for SOAP notes?
-- Impression of current condition
== What you think
What info goes in the "P" for SOAP notes?
-- What you will do
-- What you did
-- How you will do it
PART is listed where in the SOAP note?
"O" -- Part of the objective findings
What does PART mean?
P = pain/tenderness
A = asymmetry/alignment
R = ROM abnormality
T = Tissue, Tone, Texture, Temp abnormality
Is pain a subjective or objective finding?
To demonstrate a subluxation based on physical examination, 2 of the 4 PART criteria are required.
--What are they?
one of which must be A (asymmetry) or R (ROM)