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Clinic II

Tri 2

Soap Notes-Subjective Pt. Assesment of status(mini-history), Pt view or interpretation of problem, care, progress. Paraphrases/quote Pt., do not change meaning, OPQRST,
OPQRST-Onset When did it start? Time? Date? Sudden or gradual, did anything contribute?
OPQRST-Palliative/provoking What makes it worse?(Rest, time of day, positions, etc)
OPQRST-Quality Describe the pain you feel? (sharp, dull, burning throbbing etc), How would you rate the pain on a scale of 1-10.
OPQRST-Radiating Does the pain radiate to any other part of the body? If yes, describe
OPQRST-Site Describe the location including the side and level
OPQRST-Timing Is it constant or intermitant? Since when, What frequency, What is the duration?
Soap Notes-Objective Where results of msmnt are performed and the doctor's objective observations of the Pt are recorded. Objective data are the measurable and observable information used to plan the Pt treatment plan. Should be consistant and repeatable
Objective Tests leg checks, Orth tests, ROM, Posture finding, thermography readings, EMG, Neurocalamoter, Taut and Tender, Trigger Pts, Motion Palpation, Neuro tests, X-rays, MRI, Urinalysis etc
Objective for Medicare must demonstrate a subluxation and must be repeatable, must use P.A.R.T format
P.A.R.T for Medicare P-Pain and Tenderness A- Asymmetry/misalignment R-ROM abnormalities T-Tissue Tone changes
SOAP- Assessment Appraisal of Pt Progress or lack of. There are four parts to be assessed..The problem list, longterm goals, Short term goals, summary
Problem List Provides summary of Pt major complaints and is used as a reference for other health care provides. List order of importance
Long Term Goals must be structured and slearly defined, prioritizes treatment, moniters cost effectiveness
Short term goals Based on Pt complaint, immidiate course of treatment
Pt first visit list diagnosis for Pt
Pt second visit DC evaluation of Pt progress
SOAP- Plan Technique you plan to use, determine major segment to adjust, List modalities used, parameters, Referrals, NPV
Intern Records Patient File, Doctor/Clinic ID, Patient ID, Pt demographics, Healthcare coverage, Pt Hx, Exam findings, Special Studies, Misc assessment, Clinical impressions, Care Plan, Chart/Progress notes, Re-exam, Financial records
External Records Direct Coorespondence, Health records, Diag imaging, External reports
Created by: hwhite