120 likes | 246 Views
Record Keeping: CYB. Gilbert High School. Quadrants. HOPS. Done during off the field injury evaluation More detailed than the on-the-field evaluation Evaluation divided into four categories HISTORY Observation Palpation Special test. History. What happened
E N D
Record Keeping: CYB Gilbert High School
HOPS • Done during off the field injury evaluation • More detailed than the on-the-field evaluation • Evaluation divided into four categories • HISTORY • Observation • Palpation • Special test
History • What happened • Inquire about previous injuries/illnesses that may be involved as well as past treatments • Important information to obtain
History • Ask the following questions • What is the problem? • How and when did it occur? • Did you hear or feel something? • Which direction did the joint move? • Characterize the pain Pain • Pain Type • What type of pain? • Where is the pain? • Does it change at different times? • Are there any other types of sensations? • Chronic vs. Acute
Observation • How does the athlete move? Is there a limp? • Are movement abnormal? • What is the body position? • Facial expressions? • Asymmetries postural mal-alignments or deformities? • Abnormal sounds? • Swelling, heat, redness, inflammation, swelling or discoloration?
Palpation • Used at the start or further into the evaluation • Bony and soft tissue palpation • Perform systematically - begin away from the injured site • Start with light pressure followed gradually by deeper pressure • Bony • Compare bilaterally • Look for abnormal gapping, swelling, abnormal protuberances associated with bone or joint
Special Test • A number of specific tests are used to test ligamentous stability for each specific joint • Allows clinician to grade severity of injury and determine extent of dysfunction
Active Range of Motion (AROM) – Athlete Doing the movement unassisted Should be first movement assessment Assess quality of movement through different ranges and planes at varying speeds and strengths Pain free throughout full range should be tested while applying force or resistance Passive Range of Motion (PROM) – Clinician is doing the movement Athlete must remain relaxed to remove influence of contractile tissue Try to classify feel of endpoints Normal Range of Motion
MMT • Manual Muscle Testing • Used to determine vary extent of injury to contractile tissue • Limitation in muscular strength is generally caused by pain • Generally performed so muscle or group of muscles can be isolated and tested through a full range while applying manual resistance
SOAP Notes • Subjective- • Statements made by athlete - primarily history information and athletes perceptions including severity, pain, MOI • Objective- • Findings based on ATC’s evaluation
SOAP Notes • Assessment- • ATC’s professional opinion regarding impression of injury • May include suspected site of injury and structures involved along with rating of severity • Plan- • Includes first aid treatment, referral information, goals (short and long term) and examiner’s plan for treatment