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C.H.A.R.T.S.
When first meeting a client/patient or upon re-assessing that client to assess progress, a good guidance system to help accurately collect information is to base the assessment on the acronym C.H.A.R.T.S. In the next few blog entries, I will break down each section. Today, I will discuss "C".
"C" stands for Chief Complaint. This is the subjective section of the client/patient interview/assessment. Here you are finding out why that person is seeking your assistance. It is also during this interview that you will decide whether there are other possible causes of the client's issues, especially any life-threatening pathologies that may contraindicate your services. If the client has a complaint of pain, you will use the O-P-Q-R-S-T question format (previous blog entry) to analyze that. Again, it is during the interview process that you want to rule out any other serious pathology that the client may have. Some things the client may tell you that would lead you to believe there is a more serious issue are the following:
1. Unexplained weight loss - Was he/she trying to lose weight?
2. Malaise/decrease in energy level
3. Fever/chills
4. Weakness/numbness
5. Fainting (loss of consciousness) or syncope (no loss of consciousness)
6. Pain at night
7. Pain at rest that is not affected by position change
8. Bowel or bladder problems
Also check out the previous blog entry on "Red Flags"
Lastly, you will want to assess that client's response to working with you.
1. Did he/she have an unusual response?
2. Was there any symptom magnification?
3. Did the symptoms improve but then return for no reason?
4. Was their pain unaffected by your session/treatment?
5. Was the pain worsened by the session/treatment (considering you were not being too aggressive)?
1. Did he/she have an unusual response?
2. Was there any symptom magnification?
3. Did the symptoms improve but then return for no reason?
4. Was their pain unaffected by your session/treatment?
5. Was the pain worsened by the session/treatment (considering you were not being too aggressive)?
All of the above information should help guide you in obtaining an in-depth description of your client's or patient's problem and will later help you in developing goals and customizing a program. Next entry will focus on "H" for History of the condition.
