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Record Keeping: CYB

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

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Record Keeping: CYB

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  1. Record Keeping: CYB Gilbert High School

  2. Quadrants

  3. 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

  4. History • What happened • Inquire about previous injuries/illnesses that may be involved as well as past treatments • Important information to obtain

  5. 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

  6. 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?

  7. 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

  8. 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

  9. 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

  10. 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

  11. SOAP Notes • Subjective- • Statements made by athlete - primarily history information and athletes perceptions including severity, pain, MOI • Objective- • Findings based on ATC’s evaluation

  12. 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

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