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
A patient returns for a follow-up session. Which documentation practice best supports continuity of care?
Answer: Reviewing and updating prior session notes before beginning assessment
Reviewing prior session notes before assessment ensures the therapist identifies trends, contraindications discovered previously, and changes in the patient's condition.
Which of the following is the correct approach when a patient refuses to disclose their complete medication list during intake?
Answer: Require full disclosure as a condition of treatment and document the refusal
Full medication disclosure is a safety requirement; if the patient refuses, document the refusal and inform them that treatment cannot safely proceed.
When documenting a patient's abdominal assessment using the four-quadrant system, which quadrant contains the cecum and appendix?
Answer: Right lower quadrant (RLQ)
The cecum and appendix are located in the right lower quadrant, making this the relevant area to note if the patient reports tenderness there.
A patient's intake form indicates a pregnancy of 16 weeks. How should this be addressed in the assessment and documentation?
Answer: Document it as an absolute contraindication and decline treatment
Pregnancy is a recognized absolute contraindication to colonic hydrotherapy due to risks of stimulating uterine contractions and causing harm to the fetus.
Which element of documentation protects the therapist legally if a patient later claims they were not warned about treatment risks?
Answer: The signed informed consent form detailing risks disclosed
A signed informed consent form documenting that risks were explained and the patient agreed to proceed is the primary legal protection for the therapist.
Which of the following patient-reported symptoms during assessment most urgently warrants a physician referral before any colonic hydrotherapy session?
Answer: Unexplained significant weight loss over the past two months
Unexplained significant weight loss is a red flag symptom that may indicate colorectal cancer or other serious pathology requiring medical investigation first.
When using a standard intake form, the section asking about previous colonoscopies or endoscopies is primarily intended to:
Answer: Identify whether the patient has a confirmed diagnosis relevant to contraindications or care planning
Prior colonoscopy results can reveal polyps, diverticular disease, or IBD diagnoses that directly affect the safety and approach of colonic hydrotherapy.