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Cyndi's Chapter 15

Cyndi's Chapter Fifteen- Nationals

QuestionAnswer
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
Created by: 19cyndi65
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