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54 Cards in this Set
- Front
- Back
Documentation |
Process of providing written information regarding client care |
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Assessment |
Process involved in evaluating or appraising a clients condition based on subjective reporting and objective findings |
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It is ok to use white out? |
True or false |
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Soap means: |
Subjective objective assessment plan |
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Subjective |
Contains clients experience his or her condition |
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Objective |
Contains therapists visual and palpatory findings |
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Assessment |
Physicians diagnosis of the clients condition |
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Plan |
Contains treatment plan as directed by the physician |
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ALIE means: |
Assessment plan implentation evaluation |
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CARE means: |
Condition of client ,action taken, response of client ,and evaluation |
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Subjective data |
Consists of any information learned from the client or clients family and friends |
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Objective data |
Measurable and quantitative and obtained by the therapist through emperical means |
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Scope of practice |
Outlines the activities and procedures that can be performed by members of a licensed profession |
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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 |
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Client has the right to refuse |
True or false |
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Treatment planning |
Documented process of planning a clients treatment or course of treatment |
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Intake form |
First element in the treatment planning process |
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Interview |
Essential component to a customized client centered treatment plan |
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Communication |
Act of exchange information through words actions behaviors body language and feelings |
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PPALM stands for |
Purpose of session pain allergies and skin conditions lifestyle and vocation medical information |
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PPALM |
Method of obtaining and recording data relevant to client assessment and treatment planning |
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Treatment plan or plan of care |
Information forms the basis for planning individual sessions and future sessions |
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HA |
Headache |
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○P |
Pain |
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ten. |
Tension |
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LBP |
Lower back pain |
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w/ |
With |
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w/o |
Without |
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post , p |
After |
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pre |
Before |
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DP |
Direct pressure |
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○M |
Massage |
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NMT |
Neuromuscular therapy |
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DT |
Deep tissue |
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○L |
Left |
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○R |
Right |
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Bl/bil |
Bilateral |
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med |
Medial |
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lat |
Lateral |
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ROM |
Range of motion |
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flex |
Flexion |
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ext |
Extension |
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LB |
Lower back |
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mj |
Major |
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m |
Minor |
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Tx |
Treatment |
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Hx |
History |
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Fx |
Fracture |
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HBP |
High blood pressure |
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C/O |
Complains of |
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mm |
Muscle |
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Try or TP |
Trigger point |
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Cl |
Client |
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PRN or prn |
As needed |