INJURY REPORTS & MEDICAL TERMINOLOGY

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Presentation transcript:

INJURY REPORTS & MEDICAL TERMINOLOGY

Injury Reports: There are 2 types of Athletic Training injury reports: H.O.P.S. History Observation Palpation Special tests S.O.A.P. Subjective Objective Assessment Plan

HOPS: HISTORY: Taking a patient history by asking questions... What happened? Where is the pain? Have you ever had this injury before? Etc.

HOPS: OBSERVTION: Observing for signs... Bruising Swelling Deformity Redness Etc.

HOPS: PALPATION: palpation is evaluation by touching or feeling the injured body part palpate for pain feel for heat to the injured area palpate for deformity feel for swelling Etc.

HOPS: SPECIAL TESTS: special tests are going to be specific to the body part injured. usually tests ligament laxity manual muscle tests testing for fractures Etc.

SOAP: SUBJECTIVE: subjective is what the patient feels or things that they can tell you that you cannot necessarily see. History Pain Headache Nausea Etc.

SOAP: OBJECTIVE: objective is the evaluation of what you can see Swelling Bruising Deformity Etc.

SOAP: ASSESSMENT: assessment would be assessing the injury using palpation and special tests

SOAP: PLAN: this would usually be the plan of action now that you know what the injury is rehabilitation or plan to get the patient back to their sport and competition.

TERMINOLOGY: Acute: sudden onset Chronic: gradual onset Atrophy: wasting away of organs or tissue Edema: swelling Ecchymosis: bruising

TERMINOLOGY: Hematoma: localized collection of blood Referred Pain: pain away from the injury site Valgus: distal aspect of limb is forced away from the midline Varus: distal aspect of the limb is forced toward the midline

ABBREVIATIONS: History: Hx Symptoms: Sx Treatment: Tx Diagnosis: Dx Fracture: Fx

ABBREVIATIONS: Left:L with a circle around it Right: ® Patient: Pt. Negative: - Positive: + c/o: complains of

ABBREVIATIONS: Pain: p with a line over it With: c with a line over it Without: s with a line over it Increase: upward arrow Decrease: downward arrow

ABBREVIATIONS: Anterior: Ant. Posterior: Post. Flexion: Flex. Extension: Ext. Laxity: Lax. Medial: Med. Lateral: Lat. Abduction: Abd. Adduction: Add.

ABBREVIATIONS: Range of Motion: ROM Active Range of Motion: AROM Passive Range of Motion: PROM Upper Extremity: UE Lower Extremity: LE Manual Muscle Test: MMT Mechanism Of Injury: MOI Falling On Out Stretched Hand: FOOSH