The Medical Record - ATS 700

HIPAA, FERPA, documentation and eval information

ICD-10 code meaning and what they’re used for

international classification of diseases (10th revision)

used to classify injuries and determine appropriate treatments

SOAP acronym and what each part consists of

subjective: what the patient tells you

objective: measurable results

assessment: what the impression/diagnosis is (can be a working diagnosis)

plan/program: what you’re going to do about it (long and short term goal)

essential knowledge for evals

sport knowledge

anatomy

biomechanics

medical terms (on separate flashcards)

etiology

cause of an illness

pathology

structural and functional changes that result from an injury

symptom

subjective measure

sign

objective measure

prognosis

prediction of an outcome of an injury

components of an eval (HIPS/HOPS)

history

inspection/observation

palpation

special/stress tests

key components of history

95% of injury can be discovered from thorough history

listen actively

asking open ended questions

use the rest of the eval to confirm or reject working diagnosis

MAPPSSO (history components)

mechanism of injury

acute or chronic

pain

previous injury

sounds

signs and symptoms

other

key components for inspection/observation

compare bilaterally

look for posture, swelling, deformity, skin discrepancies, asymmetry, old scars (SPD)

key components for palpation

start on the healthy side

on injured side start away from the injury

identify point tenderness, crepitus, swelling, malalignment of a joint/bone

tell the patient what you’re doing first

what to look for during active/passive ROM

partial or full

pain or no pain

MMT (new) scale

5: full AROM against gravity, max resistance

4: full AROM against gravity, moderate resistance

3: full AROM against gravity

2: full AROM in a gravity eliminated position

1: palpable muscle contraction

0: nothing

(+ = pain)

(- = no pain)

ligamentous tests definition and grades

applying stress in one of the cardinal planes to a ligament

grade 1: slight stretch of ligament

grade 2: partial tearing of fibers, may be some opening of the joint

grade 3: full tear of ligament, excessive motion

positive vs. negative special tests

positive: the pathology is there

negative: the pathology is not there

sensitivity vs. specificity

sensitivity: amount of true positives

specificity: amount of true negatives

circulatory tests

skin temperature and color

pulses

capillary refill

basic exam principles

do no harm

tell the athlete what you are doing

test normal side first

AROM first then PROM

warn the patient of possible exacerbations

refer if necessary