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Cyndi's Chapter 15 Hangman

 
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Question Answer
Record keeping for clients involves  written record of intake procedures, informed consent, needs assessment, recording of each session and release of information  
Charting can be defined as  the ongoing process of recording each session  
Massage treatment goals must be qualified meaning  they are mesured in terms of objective criteria  
The purpose of building a database is to  gather information on which to build the professional interaction, establish client goals and develop a plan for achieving them  
A database consists of  all the information available that contributes to therapeutic interaction  
The purpose of assessment is to  identify effective functioning and deviations from the norm  
To analyze the data gathered during the assessment, one must  consider the information based on examination, investigation and analysis in relation to outcome  
The treatment plan  is a fluid guideline developed by client and practioner  
Problem-oriented medical records including SOAP require that  The facts possiblities, logical consequences of cause and effect and impact on persons be noted on the record  
Which of the following would be recorded in the objective data section of the SOAP note  Observation and palpation indicate upper chest breathing  
In SOAP notes=The most important area in terms of determinin future intervention procedures based on results is  A: analysis- what worked and what did not  
The P part of the SOAP should include  Plan= P: client self care  
The purpose of using a clinical reasoning model is  to be able to think through an intervention process and justify the effectiveness of a therapeutic interaction  
Angioplasty  Surgical repair  
Myalgia  Muscle pain  
Vasodilation  cardiovascular system  
What needs to be done to develop a valid analysis of massage benefits in SOAP chart  Preassessment and postassessment procedures  
Client goal "reducing neuritis" how should this be noted  Provide a decrease in nerve inflamation  
"Palpation identified mild scoliosis" should be listed where in the SOAP notes  O: observation