SOAP notes - ANSWERS-subjective, objective, assessment, plan
EMR - ANSWERS-electronic medical record
more narrowly focused detailed history
EHR - ANSWERS-electronic health record
more broad "snap shot" of history
popular EHR companies - ANSWERS-cerner, epic, all scripts
paper vs electronic documentation - ANSWERS-if providers can show
meaningful use they can get financial support
government incentives to switch to electronic documentation -
ANSWERS-3 phase program
began in 2011-2012
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medical history form - ANSWERS-longer version of health history form
can be filled out by the individual or they can be asked questions
use judgement
ask if they would like assistance
health screening form - ANSWERS-shorter version of medical history
form
not to be used with high risk patient or patient with doctor prescribed
exercise
informed consent document should include - ANSWERS-purpose and
explanation of the test
clients risks and discomforts
responsibilities of the client
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benefits to be expected
inquiries
use of medical records
freedom of consent
physician release forms - ANSWERS-not needed by those that do not
need medical clearance
fitness assessment form - ANSWERS-allows recording of VO2 max,
1RM, flexibility, etc.
fitness goals - ANSWERS-keep goals limited to start out with
"likert scale" to rate commitment/importance to goals
fitness contract - ANSWERS-not a binding contract
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