Lecture 2 - Introduction to Assessment

Question 1

2 Purposes of client interviews

Answer 1

1. Establish subjective history
2. Establish problem list and intervention goals

Question 2

Name the 7 elements of a client interview

Answer 2

1. Introduce self ask how to be addressed
2. Obtain consent
3. Ask reason for physio and goals/expectations
4. Clarify information related to chart review
5. Identify comorbidities
6. Identify urgent health conditions
7. Identify non-urgent health conditions

Question 3

Name the 6 communication keys

Answer 3

1. Courtesy
2. Clarity
3. Listen
4. Consider culture
5. Get on the same page
6. Watch body language

Question 4

What are the 3 headings of record keeping standards

Answer 4

1. Responsibility and accountability
2. General requirements for all records
3. Requirements for clinical records

Question 5

What goes in subjective of SOAP

Answer 5

Anything said by client and not observed in appointment/tested eg. age, demographic, OT notes, prior functional level, illnesses, medications, consent

Question 6

What goes in objective of SOAP

Answer 6

Anything tested by you during visit eg. ROM, gait, balance or postural assessments

Question 7

What goes in assessment/analysis SOAP

Answer 7

Diagnosis, prognosis or anything from problem list -> ICF model (what you think is going on based on findings)