Patient Assessment & Documentation Flashcards
7 cards from real CH practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Documentation flashcards as text
Which of the following findings during a pre-session abdominal assessment would be an absolute contraindication to proceeding with colonic hydrotherapy?
Answer: A palpable pulsating abdominal mass
A pulsating abdominal mass may indicate an abdominal aortic aneurysm, which is an absolute contraindication due to risk of rupture.
When documenting a patient's bowel movement frequency during intake, which term correctly describes fewer than three bowel movements per week?
Answer: Constipation
Constipation is clinically defined as fewer than three bowel movements per week, along with possible straining or hard stools.
A new patient reports taking warfarin daily. How should this be documented and addressed in the colonic hydrotherapy assessment?
Answer: Record it and require physician clearance before treatment
Warfarin is an anticoagulant that increases bleeding risk; physician clearance should be obtained and documented before proceeding.
Which section of the patient intake form is specifically designed to capture the reason the patient is seeking colonic hydrotherapy?
Answer: Chief complaint / presenting concern
The chief complaint or presenting concern section captures the primary reason the patient is seeking treatment in their own words.
During a post-session assessment, a patient reports feeling lightheaded. What should the therapist document first?
Answer: Vital signs and onset time of the symptom
Vital signs and symptom onset time are the priority documentation items to assess and monitor for potential vasovagal or electrolyte-related reactions.
Which SOAP note component is used to record the therapist's objective observations of the patient's abdomen during assessment?
Answer: O — Objective
The Objective (O) section records measurable, observable findings such as abdominal palpation results, vital signs, and physical appearance.
A patient discloses a history of Crohn's disease during intake. Which action is most appropriate?
Answer: Document the disclosure and defer treatment pending physician approval
Active or recent Crohn's disease is a contraindication; treatment should be deferred and physician clearance documented before proceeding.