Final Flashcards
(23 cards)
Which is a button and which is freeform:
- -Record active
- -Resting VAS
Record active = button
Resting VAS = freeform
Where do you enter information not pertaining to the chief complaint?
freeform
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
- -vital signs
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?
- Demographic
- History
- Exam
- Diagnostic studies
- ROF
- Adjustment
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?
- Regional,
- Physical
- Outcome Assessment
- Vitals
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?
- Subjective
- Objective
- Assessment
- Plan
What info goes in the “S” for SOAP notes?
– Symptoms
== 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?
Subjective
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)
Writing goals - what 3 things should be included?
- Need a tool to measure (neck pain disability index)
- Timeframe (2 weeks)
- Parameter (50% healed)
