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Documentation in Sports Medicine!
References for slide show
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Sports Medicine Goals Relief of pain Post surgical Medical problems
Muscle strength and mobility Improvement Basic function Improvement Standing Walking Grasping
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Parts of The Paper Trail
Assessment The Examination The Evaluation Diagnosis Prognosis Intervention/Treatment Re-Examination
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3 Components of the Examination/Documentation
Patient/Client Medical History Systems Review Tests and measures
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Examination: History/Current Health Status
Medical Background Age Medications Cognitive status Medical History Etiology of injury or illness Event leading to problem Co-morbities (for example low back pain would be Arthritis, osteoporosis, lack of exercise, stress level, poor self rated health, dissatisfaction with work) Duration of problem Clinical Assessments Muscle Strength & ROM Reflex Assessment
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Examination: Systems Review
Body systems musculoskeletal nervous integumentary Lymphatic & immune Respiratory Renal Reproductive Digestive Circulation
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Examination: Tests and measures
Body mechanics Gait Balance Orthotic devices Prosthetic requirements Range of motion Reflex integration Motor function
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Assessment: Evaluation
Analysis of: Examination results The environment for optimal human functioning Beneficial environmental factors Barriers to optimal functioning
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Diagnosis Follows Examination & Evaluation
Incorporates information from other medical team members Expressed in terms of movement dysfunction OR in Categories of impairments Activity limitations Participatory restrictions, Environmental influences Individual abilities/disabilities
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Prognosis Determine the need for care/intervention
Determine the desired improvement in function Determine amount of time to achieve that level Refer to another agency or health professional if treatment is not within the scope of physical therapy
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Types of Intervention or Treatment
Put into effect and modify to reach goals Manual handling Movement enhancement Physical, electro-therapeutic agents Functional training Provision of assistive technologies Patient related instruction and counseling d. Understand and demonstrate all necessary interventions of the patient treatment plan as it relates to their scope of practice.
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Intervention or Treatment continued
Prevention of: Impairments Activity limitations Participatory restrictions Disability and injury
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Intervention or Treatment continued
Health promotion Maintenance of health Quality of life Workability and fitness
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Treatment Plan continued
Coordinate the Care Plan Health care team collaborates Family and Care giver roles Ask the students who were the team members in the video working on the Care Plan?
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RE-Examination: DETERMINE THE OUTCOMES
Progress of Care Identify how to measure outcomes Measure the outcomes to interventions Modify Care Plan in response to outcomes
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Sample Treatment Plan Ask if any students have had physical treatment for an injury and if they would share their treatment plan with the class.
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Writing a Medical Record
Punctuation Avoid hyphens Semicolon(;) is used to connect two points Colon (:) is used instead of βisβ Correcting Errors Never erase or white-out Cross out with one line, write the date, and initial Signature Use your official title
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Writing a Medical Record
The ABCs Accuracy Brevity Clarity
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Accuracy Brevity Clarity Never record false information
Patient records are legal documents Keep information objective Brevity State your information concisely but enough information must be presented Use sentence fragments Use abbreviations Clarity Meaning should be immediately clear Avoid vague terminology Your handwriting should be legible
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https://www.youtube.com/watch?v=7H4892Pp qa0
H.O.P.S.
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HOPS- History History: Attitude, mental condition, and perceived physical state. Stated by the athlete. Primary Complaint Mechanism of Injury Characteristics of the Symptoms Limitations Past History
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H is for history LISTEN Purpose: Find out the symptoms.
What are the component parts? USE OPEN-ENDED QUESTIONS Depending on the injury, you may have to ask specific questions LISTEN SILENT
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Seven Attributes of a Symptom
Location: Quality: Quantity or Severity: Timing: Setting in which it occurs: Remitting or exacerbating factors: Associated Manifestations:
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Sample History Questions
When did problem start? What makes it better? What makes it worse? Is it better or worse in the morning or at night? Is it better or worse w/ breathing, urination, eating, excitement, stress, rest, movements, etc.
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History of Illness Have you had symptoms like this before?
Have you had x-rays, MRIs, or CT scans? Getting better, worse or same? Have you received any treatments? Do you have any family history of chronic disease or health concerns?
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When Pain is associated!
Type of Pain Acute vs chronic Local vs referred Constant vs intermittent Sharp? Radiating? Burning? Location Etc.!
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Purpose: Find out the signs.
I is for inspection/ O is for Observation Purpose: Find out the signs. Appearance What does it look like?, skin appearance, signs of trauma Bilateral symmetry Bleeding Color/Discoloration Deformity Edema/Swelling Expressions denoting pain
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RED FLAGS! Constant pain Heart palpitations Fainting
Night pain or sweats Difficult or painful swallowing Vision loss Unexpected weight loss Insomnia Excruciating pain Nausea, vomiting Difficult urination Blood in urine Dizziness Chronic fatigue
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HOPS- Observation and Inspection
Observation: Measurable objective signs. Appearance Symmetry General Motor Function Posture and Gait Deformity, swelling, discoloration, scars, and general skin condition
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P is for palpation Begin away from the pain & move towards the injury
Pain & Point tenderness Malalignment of joint/bone Crepitus Swelling Rule out FX Skin temperature Point tenderness Muscle spasm Capillary Refill Pulse
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S is for stress or special
Functional Tests Active Range of Motion (AROM) Passive Range of Motion (PROM) Resisted Manual Muscle Testing (RROM) Stress Tests Ligamentous Instability Tests Special Tests
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HOPS- Special Tests Neurologic Tests Sport-Specific Functional Testing
Dermatomes Myotomes Reflexes Peripheral Nerve Testing Sport-Specific Functional Testing Proprioception and Motor Coordination
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Finish it! Come to conclusions. Differential diagnosis
List the options For example β What could it be? Anterior knee pain Lateral ankle pain Your Turn:
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Daily Documentation of Injuries
Writing SOAP Notes IF YOU DONβT DOCUMENT IT, IT DIDNβT HAPPEN EecA
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The SOAP Note Organized according to the source the information
S = Subjective O = Objective A = Assessment P = Plan Sometimes preceded by a statement of the problem Usually the patientβs chief complaint, the diagnosis, or a loss of function.
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What goes where? Subjective Objective Assessment Plan
This information is received from the patient Objective Results of tests measurements performed and the therapistβs objective observations Break into separate body parts if necessary Assessment Probable or Differential Diagnosis Plan
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S.O.A.P. Notes What are SOAP notes?
S.O.A.P. notes are a concise format of effectively documenting the initial evaluation and progress notes for the injured athlete. They are part of a system designed to record subjective and objective findings and to document the immediate and future treatment plan for the athlete.
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S.O.A.P. Notes Which health care professionals use SOAP notes?
Athletic Trainers Chiropractors Physical Therapists Other health care professionals
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S.O.A.P. Notes What is the benefit of using SOAP Notes?
The standardization of a note-taking format makes it easier to transfer patients between providers.
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(CC) = βChief Complaintβ:
What is written in this section? The first thing the athlete tells you. Example(s): If the athlete/patient comes into the training room/clinic and says, βI hurt my armβ or βmy knee is really sore,β you would write: βCC: Right arm painβ or βCC: Left knee soreness.β
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(CC) = βChief Complaintβ:
What is the purpose of this section? It makes it easier for the athletic trainer, when looking back through the notes or trying to remember what their original complaint was, to easily identify what area of the body has been injured.
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(S) = Subjective: What is described in this section?
This part of the notes is made up of the subjective statements provided by the injured athlete/patient. The athlete/patient tells the healthcare provider about the injury relative to the history or what he/she felt.
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(O) = Objective: What is described in this section?
The objective portion documents information that the healthcare provider gathers during the evaluation.
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SOAP- Objective: Observation: Measurable objective signs. Appearance
Symmetry General Motor Function Posture and Gait Deformity, swelling, discoloration, scars, and general skin condition
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Findings will include:
Visual inspection Palpation Assessment of active, passive, and resistive motion Additional findings such as posture, presence of deformity or swelling, and location of point tenderness will also be noted here.
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Visual Analog Scale = Have the athlete rate their pain level on a scale of zero to 10: β10β being the worst pain they can imagine β0β being no pain at all
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(A) = Assessment: What is described in this section?
The healthcare providers professional opinion about the nature of the injury. What is important to remember about this section? As a student you are not allowed to make the final diagnosis of an injury.
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SOAP- Assessment Analyze and assess the individualβs status and prognosis Suspected injury Site Damaged Structures Involved Severity of Injury Progress Notes
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Example(s) of what may be written in this section:
βGrade II Right lateral ankle sprainβ βGrade II Tear of the Lateral Head of the Gastrocnemiusβ βCervical Spine Sprain/Strain post-MVAβ\ βRight Subacromial Bursitisβ
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(P) = Plan: What is described in this section?
Your plan for treatment of the athleteβs/patientβs injury. This section should include the first aid treatment rendered (e.g. application of splint, wrap, or crutches) to the athlete and the intentions for future treatment.
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SOAP- Plan Immediate treatment given
Frequency and duration of treatments and modalities and evaluation On-going patient education Criteria for discharge/return to play
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This section should also include:
Doctor referrals Short-term goals Long-term goals When the athlete/patient will return for treatment
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