| 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 |
Cynthia Vanderweel
on 2009-04-16
MedTemCP5 Word+Pics
