O: objective (objective info ex. blood pressure readings)
A: assessment (progress and evaluation of plan effectiveness)
P: plan of action (decision to proceed or alter strategy Ex Rx)
Correction on SOAP notes - ANSWERSCareful clarification of an error when making an entry in a medical
record is essential.
Include:
Date
The abbreviation "corr"
Initials of person making corrections
Do not use correction fluid!
In electronic databases - initial your corrections and date.
*S* OAP - ANSWERSHealth or Medical History
from patient including his/her perceptions
,The patient's chief complaint and/or recall of his or her personal medical history including past injuries,
illnesses, operations, defects, and habits
S*O*AP - ANSWERSPhysical Exam, data from previous medical records and laboratory reports; Includes:,
history of present illness, past history, family history, occupational history and review of systems
Facts and observations made by an examiner
SO*A*P - ANSWERSAssessment: any type of testing
Group assessments by type of exercise or by physiological problem.
Be assessing multiple problems, and consider independently & interactively.
Keep records to assess time course of medications and exercise changes.
Determine exercises by trial-and-error if assessments are not feasible
SOA*P* - ANSWERSPlan- therapy or exercise plan
Include short and long term goals
SMART goals
SMART Goals - ANSWERSSpecific: Choose the type of exercise tests and modes of exercise that best fit
the condition and individual.
Measureable: Set realistic goals.
Actionable: Client must believe in the exercise goals and plan.
Realistic: most benefits will be quality of life and may not be objectively measured.
Time oriented: Set a date for re-evaluation or monitoring progress.
When problem oriented management is needed... - ANSWERSNot needed: able bodied, single problem
Helpful for: chronic multiple problems
What two tenets should you remember as you begin your interview with a client? - ANSWERSAll
interactions are confidential "What happens in the lab....stays in the lab!"
, When examining patients, maintain their modesty; some patients have modesty standards that are very
different
What to observe for during S*O*AP? Why? - ANSWERSConcentrate on any abnormal findings
Evaluate HR, BP, laboratory test results (e.g., CHOL)
Hair, nails, teeth, edema, other?
Gait, joints, strength, back pain
Metabolic, infection
Why?: to determine if its safe for client to exercise
Antalgic gait - ANSWERSlimping from unilateral pain
Hemiplegic gait - ANSWERSweakness or paralysis
Parkinsonian gait - ANSWERSShuffling gait
Hemiplegic, shuffling, wide-based, foot-drop, and slapping gaits all represent ... -
ANSWERScompensation for underlying neurologic disease such as a spinal cord injury, or midbrain
dysfunction (e.g., Parkinson's disease) & leave the patient prone to falling
A slow gait is often a tipoff for... - ANSWERS... back disease, hip arthritis, or underlying neurological
problems
Red Flags of Change in Clinical Status - ANSWERSNew-onset or definite change in pattern of shortness of
breath or chest pain
Complaint of recent syncope (loss of consciousness) or near syncope
Neurologic symptoms suggestive of transient ischemic attack (vision or speech disturbance)
Recent fall
Lower leg pain at rest (also called critical leg ischemia)
Severe headache
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