HELP ASAP 4.07 Lab AnatomyPhys
Examining Muscle Movement
Step One-Creating Your Electronic Record Template

Many years ago, all hospitals and healthcare professionals would fill out patient charts by hand, storing them all in secure filing cabinets. In fact, many facilities still store quite a bit of patient information in hard copy form! However, medical professionals today are quite likely to use some form of online records management, often abbreviated as EMR (electronic medical record). This allows you to quickly look up patient information stored in an online or local database, rather than shuffling through physical files. EMR software can even make it easier to share information across medical sites—for example, your primary care physician might record allergies and which medications you are on, then your pharmacist can check against these when filling a prescription, hopefully avoiding adverse reactions or harmful pharmaceutical interactions.

Using a template that you find online or one you create yourself, you will record your patient’s visit in a word processing document and save it to be uploaded to their electronic medical record. The medical note you will be taking today will be the observations and results of a Range of Motion test. On your form, be sure to include a place to record readings for the following:

Upper body:

Five neck readings
Three left shoulder and three right shoulder
One left elbow, one right elbow
One left forearm, one right forearm
Two left wrist and two right wrist
Three left thumb and three right thumb
Two left finger movements and two right finger

OR

Lower body:

Three left hip movements and three right hip
One left knee and one right knee
One left ankle and one right ankle
One left foot and one right foot
Four left toe movements and four right

You will want to make sure that your note has room for a summary and a diagnosis.

Once you have your medical note ready, move on to the next step: performing the exam.
STEP TWO- EXAMINING YOUR PATIENT

Today you will perform a range of motion test to assess a patient’s movement. We’ll use a fairly general test, which can be found here:
Brooksidepress. org: Basic Patient Care Procedures - Range of Motion

Ideally, you’ll run through this with a partner so you can more easily observe the results, but you can check most of the positions and motions using a mirror, if you prefer to do it yourself.

You also need to choose (and note) whether you are engaging in passive motions (RoM exercises in which someone does the movement for the patient) or active motions (RoM exercises in which the patient moves themselves).

If you are working with a partner, try at least a couple of the tests as passive motions; if you are testing yourself, you can still sample passive motions by using other body parts to move the part you’re testing.

Another thing to keep track of when doing the test is the difference between objective and subjective observations. Objective observations, the bulk of your notes, will record measurable, specific ranges of motions. However, sometimes medical professionals will observe things that are harder to describe in objective, discrete metrics—for example, if the patient seemed to have trouble completing the movement, even though the objective measurements give a full range of motion. Did they show any signs of pain as they completed the motion? You want to be sure to track these observations as well!

On your electronic form, track your specific notes for each exercise: for example, you will have five entries for the range of motion for the neck. Remember, you will be checking both left and right sides for many of these motions; in the neck, it will be for rotation and lateral flexion. Use the precise positional language when recording your findings.

Try to use a combination of subjective and objective language to capture your patient’s performance on the RoM tests.

So, your objective fifth entry might read, “Active test of Lateral Flexion of the neck, 45 degrees right to 30 degrees left.” A subjective entry might read, “Subjectively: When flexing to the left, patient winced and seemed to struggle to complete the exercise.”

Complete this for either the upper-body OR lower-body motions.

Once you’ve completed all the RoM tests, summarize the results. For many patients, this would leave you writing in the notes “performed full RoM tests; no significant abnormalities detected.” Or, you might note that there was limited motion in one of the tests; maybe your patient recently injured themselves and are still recovering. If the patient showed difficulty or pain with a movement, make a note in the chart of which muscle may be causing the discomfort. (You may need to do some research to find the correct term for this muscle.)

Along with your summary, make sure that you enter a diagnosis.