Cyndi's Chapter Fifteen- Nationals
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| Record keeping for clients involves | written record of intake procedures, informed consent, needs assessment, recording of each session and release of information
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| Charting can be defined as | the ongoing process of recording each session
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| Massage treatment goals must be qualified meaning | they are mesured in terms of objective criteria
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| 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
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| A database consists of | all the information available that contributes to therapeutic interaction
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| The purpose of assessment is to | identify effective functioning and deviations from the norm
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| To analyze the data gathered during the assessment, one must | consider the information based on examination, investigation and analysis in relation to outcome
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| The treatment plan | is a fluid guideline developed by client and practioner
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| 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
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| Which of the following would be recorded in the objective data section of the SOAP note | Observation and palpation indicate upper chest breathing
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| 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
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| The P part of the SOAP should include | Plan= P: client self care
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| 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
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| Angioplasty | Surgical repair
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| Myalgia | Muscle pain
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| Vasodilation | cardiovascular system
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| What needs to be done to develop a valid analysis of massage benefits in SOAP chart | Preassessment and postassessment procedures
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| Client goal "reducing neuritis" how should this be noted | Provide a decrease in nerve inflamation
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| "Palpation identified mild scoliosis" should be listed where in the SOAP notes | O: observation
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