PATIENT ASSESSMENT

Duty of care All practitioners have a duty of care towards any person who asks for their help.

It is essential that if someone asks you in an ‘out of business’ situation for ‘just a quick bit of help’, that you explain you will be writing this down as you are profession-

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■ Information Commissioner’s Office - www.ico.gov.uk

■ DirectGov - www.direct.gov.uk/ Homepage/ fs/en

■ Data Protection Act 1998 - www.opsi.gov.uk/ACTS/acts1998/ 19980029.htm

RATE, DEPTH

TEMPERATURE, COLOUR, CONDITION, ALTERED SENSATION

ally bound to do so. In the long run the safest action here is to say ‘Sorry I only consult at my practice.’ You would be amazed at the number of charges that have arisen from an ‘off the cuff’ bit of advice. It is also well worth remembering that your professional liability insurance only covers you for those treatments that you have been trained in, in accordance with your professional Code of Conduct and Standards of Practice set by your professional body.

EXAMINATION Having taken the history, the next step in assessment is to proceed to examination. Once more this section can be divided into two main parts. 1) Subjective assessment 2) Objective assessment

Subjective assessment This refers to the information given by the patient about the reason and particular his- tory for their attendance for treatment. It is therefore a personal tale from the person and should be noted in the records as such. Obviously this may be biased and most often be expressed in lay terminology. You can assist the content by questioning but record both question and answer. If you do

www.sportex.net A DIFFERENCES ANY

inspection of footwear and any equip- ment involved in the activities.

WHEN KNOWS BEING OBSERVED, AT REST

Observation Note how the person moves, any limp, pro- tection of part, reluctance to move, altered posture. Much can be learnt from an appar- ently casual look as the patient enters the treatment area, sits down, stands up, or writes.

Measurement The objective assessment contains all the measurable quantitative data relating to the patient. This can be range of movement whether passive, active assisted or resist- ed. Specific joint or muscle tests, all func- tional activities and sport specific move- ments which can include equipment usage.

A very useful protocol is the Record Assessment Protocol – RAP. This is a logi- cal progression to assist in ensuring all areas are looked at.

The Pain Scale is also very useful to use and can demonstrate improvement or not if

NOTE FULL RANGE, LOSS, INCREASE

Ensure that records are: ■ Clear ■ Logical ■ Legible ■ Signed ■ Stored.

A practitioner must: Ask

Note Observe Active movement Listen

Please explain Look

Range

Passive movement Range Resisted movement Range Specific test

Specific activities

Decide Fit?

THE AUTHOR Joan Watt, MCSP, MSMA is a chartered physiotherapist and sports massage practi- tioner. She has worked at numerous Olympic and Commonwealth games, con- tinues to travel widely as both a practi- tioner as well as a manager and is current- ly manager of the GB Shooting team.

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S FURTHER READING

■ Informed Consent - www.bmj.com/ cgi/ collection/informed_consent

■ Patient confidentiality - www.dh.gov.uk/ PolicyAndGuidance/InformationPolicy /PatientConfidentialityAndCaldicottGu ardians/fs/en

■ Enhanced Disclosure Certificate Application - www.crb.gov.uk

FORWARDS,

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not understand anything ask for more explanation. It is always useful to note the patient’s main concern.

Objective assessment This in turn deals with the observation, measurement, specific tests and functional activities an progresses to palpation and

used regularly. There are many variations of scales. An example is shown in figure 1.

Objective assessment summary The goal of this stage of assessment and which can pertain to any treatment inter- vention, is to provide S.O.A.P. notes These are: S – subjective – patient explains O – objective – practitioner observes, tests, palpates

A - analysis – reasoned results P – plan – immediate, goals, outcome.

INTERACTIVE 1 PRINTABLE EXTRAS

■ Chaperone clinic sign ■ A3 practitioner prompt ■ Patient assessment form

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