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Intro To Clinicals > Final > Flashcards

Flashcards in Final Deck (23):
1

Which is a button and which is freeform:
--Record active
--Resting VAS

Record active = button

Resting VAS = freeform

2

Where do you enter information not pertaining to the chief complaint?

freeform

3

What is the differential diagnosis?

list of potential diagnosis

4

What is a diagnostic study?

studies that go above and beyond what is done in the office (i.e. lab work, CT's, etc.)

5

What is a prognosis and how is it classified?

How you expect the patient to do
--(poor, fair, good, excellent)

6

What 4 forms are used with a new patient encounter?

-- Health questionnaire
-- History form
-- Post history critical thinking form
-- Post exam critical thinking worksheet

7

A basic physical exam includes what 3 things?

-- System exam relating to the complaint
-- comprehensive ortho-neurological exam
--vital signs

8

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.)

9

The process involved in starting a patient and working up to an adjustment includes what 6 things?

-- Demographic
-- History
-- Exam
-- Diagnostic studies
-- ROF
-- Adjustment

10

Where should you wear your badge?

on collar or lapel

11

When is a clinic jacket required?

if not wearing clinic approved polo

12

What constitutes an exam in the clinic?

-- Regional,
-- Physical
-- Outcome Assessment
-- Vitals

13

What goes on a radiology requisition?

-- Clinical impression
-- Reason for taking Xray
-- Patient history
==== (is it gold standard, what to do if positive)

14

What are the parts of a SOAP note?

-- Subjective
-- Objective
-- Assessment
-- Plan

15

What info goes in the "S" for SOAP notes?

-- Symptoms
== What the patient tells you

16

What info goes in the "O" for SOAP notes?

-- Measurable and Observable data
== What you found

17

What info goes in the "A" for SOAP notes?

-- Impression of current condition
== What you think

18

What info goes in the "P" for SOAP notes?

-- What you will do
-- What you did
-- How you will do it

19

PART is listed where in the SOAP note?

"O" -- Part of the objective findings

20

What does PART mean?

P = pain/tenderness
A = asymmetry/alignment
R = ROM abnormality
T = Tissue, Tone, Texture, Temp abnormality

21

Is pain a subjective or objective finding?

Subjective

22

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)

23

Writing goals - what 3 things should be included?

-- Need a tool to measure (neck pain disability index)
-- Timeframe (2 weeks)
-- Parameter (50% healed)