COMPLETE SOLUTIONS GRADED A++
SOAP notes
subjective, objective, assessment, plan
EMR
electronic medical record
more narrowly focused detailed history
EHR
electronic health record
more broad "snap shot" of history
popular EHR companies
cerner, epic, all scripts
paper vs electronic documentation
if providers can show meaningful use they can get financial support
government incentives to switch to electronic documentation
3 phase program
began in 2011-2012
medical history form
,longer version of health history form
can be filled out by the individual or they can be asked questions
use judgement
ask if they would like assistance
health screening form
shorter version of medical history form
not to be used with high risk patient or patient with doctor prescribed exercise
informed consent document should include
purpose and explanation of the test
clients risks and discomforts
responsibilities of the client
benefits to be expected
inquiries
use of medical records
, freedom of consent
physician release forms
not needed by those that do not need medical clearance
fitness assessment form
allows recording of VO2 max, 1RM, flexibility, etc.
fitness goals
keep goals limited to start out with
"likert scale" to rate commitment/importance to goals
fitness contract
not a binding contract
is a motivator for individual
let them know they will be held accountable
physical activity
any bodily movement produced by the contraction of skeletal muscles that results in a
substantial increase in energy expenditure
exercise
a type of physical activity that is planned, structured, and repetitive done to improve or
maintain one or more components of physical fitness
physical fitness