musculoskeletal system

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Example:
You will perform a history and assessment of a musculoskeletal problem. You will document your subjective and objective findings, identify actual or potential risks, and submit this document to the dropbox provided. Your subjective portion of the documentation should briefly describe your “client”. For example, “This client is a 23-year-old white female complaining of a painful, swollen ankle. States that she stepped ‘funny’ off a step two days ago and thinks she heard a ripping sound. She takes no medications and has no allergies. The client reports pain as 5/10 with sharp twinges when trying to walk, resting and ice decreases pain to 2/10 aching. Pain is primarily in the outer aspect of the ankle and foot. Has no prior injury to this area. No significant past medical history.” Write your subjective paragraph at the end of the document under the potential risk factors. In terms of your objective findings, assess only the area related to the problem (using the example above, you would only assess the ankles). If they are c/o knee pain, only assess the knees. Remember to only record what you have assessed. As you are filling out the form, try to avoid words such as normal, appropriate. For example, if you are assessing an ankle, you would want to say L ankle visually larger than R. Erythema noted around L malleoli, area warm to palpation. Do not make a diagnosis or state the cause of a finding. You are not coming to any conclusions within your documentation. When your documentation is complete, you will note any findings that were abnormal.

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