Chapter 3: Case Study

Question 1

What documents can be found in each client’s Case Study?

Answer 1

• Client Waiver
• Consent and Privacy form
• Health Record pages 1 and 2
• First Session Form
• Follow up session forms

Question 2

Give three reasons for the Health Record.

Answer 2

• Reference document for future sessions. E.g. date of initial session
• Able to track improvements
• Tender reflexes can be located based on the client’s presenting problem (s)
• Identify short- and long-term goals
• Establishes a professional standard
• Recognize and refer client to different health provider when in their best interest

Question 3

Describe what to do when documenting a treatment.

Answer 3

i) Develop a glossary of symbols. Use these symbols on the initial and follow up treatment records
ii) Complete the diagram on the appropriate Treatment Record using the glossary of symbols
iii) Review the assessment questions on the Treatment Record and complete your assessment and session by recording the answers and observations

Question 4

What are the assessment questions?

Answer 4

iv) Did you:
a) identify physical deviations such as calluses?
b) Note all areas of tenderness and describe degree of change?
c) Mark areas in which disturbances were noted under the skin?
d) Include what the client said, what you did and evaluation of the treatment?

Question 5

What are three reasons for a Treatment Record?

Answer 5

i) To record any complications or questions concerning the treatment
ii) To help you to remember tender reflexes
iii) To track improvements in the client’s health
iv) To evaluate the treatment plan