QUESTIONS WITH COMPLETE SOLUTIONS GRADED A++
Purpose of Documentation
To protect organizations, professionals, and clients. Usually digital nowadays
SOAP Notes
subjective, objective, assessment, plan.
EHR vs EMR
EMR is more detailed with medically-detailed history. EHR is more about their health
and to share
When did documents switch to electric?
Around 2011 and 2012 because the government was giving incentives to go digital
Medical History Form
Longer version of a health screening, can be filled out by patient or provider
Health Screening Form
Shorter version of medical history form, not used with high risk population
Informed consent includes
1. Purpose and explanation
2. Client risk and discomforts
3. Responsibilites of client
4. Benefits to be expected
5. Inquiries
, 6. Use of medical records
7.Freedom of consent
Physician's Release Form
When the provider releases the patient's medical history to you because you need it
ACSM Risk Classification
Low: Asymptomatic who have no CVD risk factors
Moderate: Asymptomatic who have more or equal to 2 risk factors
High: Known CVD, Pulmonary, or Metabolic Disease. Or, people who have any signs or
symptoms of any of them
Major CVD, Pulmonary, Metabolic Disease Signs and Symptoms
-Pain in neck, jaw arms, related to ishchemia
-Shortness of breath at rest or mild exertion
-Dizziness or syncope
-Orthopnea or paroxysmal nocturnal dyspnea
-Ankle Edema
-Palpitations or tachycadia
-Internmitten claudication
-Known heart murmur
-Unusual fatigue or shortness of breath with activity
Fitness Assessment Form
Recording items like VO2 max, 1RM, musculoskeletal flexibility
Exercise Prescription Interview Form