Clinical Assessment BASICS
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- Term denoting the disease or syndrome
a person has or is believed to have
(Taber's)
- Identification of a disease by history,
physical examination, laboratory studies,
diagnosis and radiological
studies (Taber's)
- Identification and naming of a disease
or pathology
Protected act under the 'Regulated
Health Professions Act' (RHPA)
- An appraisal or evaluation of a patient's
condition....(Taber's)
- An educated evaluation of a patient's
condition and physical basis for their
symptoms
(Rattray/Ludwig)
assessment
- A means to fully understand the pa-
tient's problems, from the patient's per-
spective as well as the
clinician's, and the physical basis for the
symptoms that have caused the patient
to complain (Magee)
- Any loss or abnormality of psycholog-
ical, physiological, or anatomical struc-
ture or function
- THIS of patient's body structure or func-
impairment tion
- Can occur as a result of a medical con-
dition, pathology or injury
- Can be applied to the wellness model of
care as well
We assess for THIS reason:
- Identify possible red flags (serious un-
derlying pathology)
[to create a] safe treatment plan
- Previous injury that may contraindicate
certain techniques.
- Medications
, Clinical Assessment BASICS
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- Underlying pathology or health condi-
tion that may contraindicate treatment
We assess for THIS reason:
- Identify patients goals
- Identify impairments
- Establish goals of treatment
- Facilitates treatment that has direction
[to create an] effective treatment plan
and intent
- Ensures that you are treating the cause
of the complaint, otherwise treatment will
yield poor
results
We assess for THIS reason:
- Objective means to monitor results of
[a tool to monitor the] progress/effective-
treatment, self care, function
ness [of treatment]
- Provides information for informed clini-
cal decision making
We assess for THIS reason:
- Must be able to speak the language oth-
[to] communicate to other(s) [health care
er practitioners will understand (doctors,
professionals]
physiotherapists, chiropractors, etc...)
- Professional image
We assess for THIS reason:
[it's] required by law
- CMTO standards, RHPA, MTA
Which letter of SOAP notes is this?
- Patient's perception of the current
symptoms and their health history (what
they tell you)
- On the initial visit this would include the
health history and answers to the ques-
subjective [SOAP] tions asked by the
therapist during the interview
- This information is VERY IMPORTANT
to the assessment process, and should
not be overlooked
- On subsequent visits this section
should include how the patient has been
Study online at https://quizlet.com/_96jhsx
- Term denoting the disease or syndrome
a person has or is believed to have
(Taber's)
- Identification of a disease by history,
physical examination, laboratory studies,
diagnosis and radiological
studies (Taber's)
- Identification and naming of a disease
or pathology
Protected act under the 'Regulated
Health Professions Act' (RHPA)
- An appraisal or evaluation of a patient's
condition....(Taber's)
- An educated evaluation of a patient's
condition and physical basis for their
symptoms
(Rattray/Ludwig)
assessment
- A means to fully understand the pa-
tient's problems, from the patient's per-
spective as well as the
clinician's, and the physical basis for the
symptoms that have caused the patient
to complain (Magee)
- Any loss or abnormality of psycholog-
ical, physiological, or anatomical struc-
ture or function
- THIS of patient's body structure or func-
impairment tion
- Can occur as a result of a medical con-
dition, pathology or injury
- Can be applied to the wellness model of
care as well
We assess for THIS reason:
- Identify possible red flags (serious un-
derlying pathology)
[to create a] safe treatment plan
- Previous injury that may contraindicate
certain techniques.
- Medications
, Clinical Assessment BASICS
Study online at https://quizlet.com/_96jhsx
- Underlying pathology or health condi-
tion that may contraindicate treatment
We assess for THIS reason:
- Identify patients goals
- Identify impairments
- Establish goals of treatment
- Facilitates treatment that has direction
[to create an] effective treatment plan
and intent
- Ensures that you are treating the cause
of the complaint, otherwise treatment will
yield poor
results
We assess for THIS reason:
- Objective means to monitor results of
[a tool to monitor the] progress/effective-
treatment, self care, function
ness [of treatment]
- Provides information for informed clini-
cal decision making
We assess for THIS reason:
- Must be able to speak the language oth-
[to] communicate to other(s) [health care
er practitioners will understand (doctors,
professionals]
physiotherapists, chiropractors, etc...)
- Professional image
We assess for THIS reason:
[it's] required by law
- CMTO standards, RHPA, MTA
Which letter of SOAP notes is this?
- Patient's perception of the current
symptoms and their health history (what
they tell you)
- On the initial visit this would include the
health history and answers to the ques-
subjective [SOAP] tions asked by the
therapist during the interview
- This information is VERY IMPORTANT
to the assessment process, and should
not be overlooked
- On subsequent visits this section
should include how the patient has been
