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Chapter 5 The Patient/Client Management Format: History The examination section has 3 subsections: History Systems Review Tests & Measures History Identifying Information Current Conditions/Chief Complaints Social History Employment Status Living Environment General Health Status Social/Health Habits Family Health History Patient’s Medical/Surgical History Functional Status/Activity Level Medications Growth and Development Other Clinical Tests * Not every category may be used with every patient. Abbreviations & Medical Terminology Appropriate abbreviations and terminology is expected Correct spelling Concise Do not need to use full sentences Do not need to identify source of information, unless conflicting information is given Organization Headings or subcategories may be used Example: Social History: Lives alone. Employment: Works full time inside of home. General Health Status: Rates general health as fair. Chapter 6 The Patient/Client Management Format: Writing Systems Review Information in this section is often listed as not impaired or impaired Specific descriptions and measurements are written in Tests & Measures section Categories Used to Report the Systems Review Cardiovascular/Pulmonary Integumentary Skin color, texture, disruption Musculoskeletal Heart Rate, Blood Pressure, Edema Symmetry, range of motion, strength Neuromuscular Gait, balance, motor control Communication, Affect, Cognition, and Learning Style Emotions, vision, hearing inabilities, language barriers Chapter 7 The Patient/Client Management Format: Documenting Tests & Measures Tests & Measures are measurable or observable Can be repeated during treatment to evaluate progress Categories Based on profession and types of tests & measures performed Examples: Ambulation Transfers Balance Range of Motion (ROM) Strength Sensation Methods of Recording Data From Tests & Measures Complete sentences are not necessary Tables, charts, flow sheets Include patient’s name and date Chapter 8 The SOAP Note: Stating the Problem SOAP notes use the same information as the Patient/Client Management Format, but organizes according to the source of information instead of the type of information The problem is often stated before the SOAP note begins The problem is the patient’s chief complaint or diagnosis Chapter 9 The SOAP Note: Writing Subjective (S) The Athletic Trainer states the information received from the patient that is relevant to the patient’s present condition Similar to the History section of the Patient/Client Management Format Categorizing Items as Subjective Current conditions/chief complaint Functional status/activity level Social history Employment status Living environment General health status Social/health habits Family health history Medical/Surgical history Medications Growth & Development Other clinical tests Response to treatment interventions Patient’s goals Anything else Use of the Term Patient Use “patient” the first time but do not repeat with every sentence Abbreviations and Medical Terminology Appropriate abbreviations and terminology is expected Correct spelling Concise Do not need to use full sentences Do not need to identify source of information, unless conflicting information is given Organization Headings or subcategories may be used Do not include information or subcategories in the note just for the sake of inclusion Verbs Use of verbs indicates that the statements are subjective Examples: States, describes, denies, indicates Quoting the Patient Verbatim Use direct quotes to show confusion, memory loss or denial, or to describe pain Chapter 10 The SOAP Note: Writing Objective (O) The Objective section includes result of test and measurements and the Athletic Trainer’s observations Data is measurable or observable and can be repeated during treatment to evaluate progress Categories Athletic Trainer’s inspection and observation Palpations Deformity, discoloration, swelling, gait, how athlete carries themselves Bony landmarks, soft tissue Special Tests Special tests, range of motion, strength, balance, sensation HIPS/HOPS Method History (S) Inspection/Observation (O) Palpation (O) Special Tests (O)