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Assessment Layout

  1. Definition
    • Evaluation the nature of condition
    • An assessment performed by an RMT is not a diagnos by law
  2. 5 parts of Assessment
    1. Health history and Questionnaries
      1. Cheif complaint : LO DR FICARA
        1. Location / Origin / Duration / Radiation / Frequency / Intensity / Character / Aggravating factors / Reliving factors / Associated symptoms
      2. Medical history
      3. Secondary complaint
    2. Observation
      1. Support equipment / functional abilities
      2. Facial expression
      3. Scars / soft tissue / skin color / nail bed
      4. Posture
      5. Gait
    3. Palpation
      1. Consent
      2. Tips on palpation
      3. 4Ts ; temperature, tenderness, tone, texture
    4. ROM
    5. Neurological examination
    6. Orthopaedic testing
  3. SOAP note
    1. Subjective : All information clients tell you
      1. Symptoms
      2. Health history
    2. Objective : All informatin examiner obtains from testing and history
      1. Observation / sign
      2. Palpation
      3. ROM
      4. Neurological / Orthopaedic testing
    3. Assessment : what condition you are treating the client for
    4. Plan of management : What your treatment will consist of
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