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54 Cards in this Set

  • Front
  • Back

Documentation

Process of providing written information regarding client care

Assessment

Process involved in evaluating or appraising a clients condition based on subjective reporting and objective findings

It is ok to use white out?

True or false

Soap means:

Subjective objective assessment plan

Subjective

Contains clients experience his or her condition

Objective

Contains therapists visual and palpatory findings

Assessment

Physicians diagnosis of the clients condition

Plan

Contains treatment plan as directed by the physician

ALIE means:

Assessment plan implentation evaluation

CARE means:

Condition of client ,action taken, response of client ,and evaluation

Subjective data

Consists of any information learned from the client or clients family and friends

Objective data

Measurable and quantitative and obtained by the therapist through emperical means

Scope of practice

Outlines the activities and procedures that can be performed by members of a licensed profession

Informed consent

Permission for treatment given by a client after he or she has been informed of the risks, benefits, and consequences of the technique and procedures

Client has the right to refuse

True or false

Treatment planning

Documented process of planning a clients treatment or course of treatment

Intake form

First element in the treatment planning process

Interview

Essential component to a customized client centered treatment plan

Communication

Act of exchange information through words actions behaviors body language and feelings

PPALM stands for

Purpose of session pain allergies and skin conditions lifestyle and vocation medical information

PPALM

Method of obtaining and recording data relevant to client assessment and treatment planning

Treatment plan or plan of care

Information forms the basis for planning individual sessions and future sessions

HA

Headache

○P

Pain

ten.

Tension

LBP

Lower back pain

w/

With

w/o

Without

post , p

After

pre

Before

DP

Direct pressure

M

Massage

NMT

Neuromuscular therapy

DT

Deep tissue

○L

Left

○R

Right

Bl/bil

Bilateral

med

Medial

lat

Lateral

ROM

Range of motion

flex

Flexion

ext

Extension

LB

Lower back

mj

Major

m

Minor

Tx

Treatment

Hx

History

Fx

Fracture

HBP

High blood pressure

C/O

Complains of

mm

Muscle

Try or TP

Trigger point

Cl

Client

PRN or prn

As needed