CH Patient Assessment & Documentation 2 — Questions and Answers
Question 1: Which of the following findings during a pre-session abdominal assessment would be an absolute contraindication to proceeding with colonic hydrotherapy?
- Mild bloating reported by the patient
- A palpable pulsating abdominal mass (Correct answer)
- Soft bowel sounds on auscultation
- Mild tenderness in the left lower quadrant
Correct answer: A palpable pulsating abdominal mass
A pulsating abdominal mass may indicate an abdominal aortic aneurysm, which is an absolute contraindication due to risk of rupture.
Question 2: When documenting a patient's bowel movement frequency during intake, which term correctly describes fewer than three bowel movements per week?
- Diarrhea
- Constipation (Correct answer)
- Dysbiosis
- Dysmotility
Correct answer: Constipation
Constipation is clinically defined as fewer than three bowel movements per week, along with possible straining or hard stools.
Question 3: A new patient reports taking warfarin daily. How should this be documented and addressed in the colonic hydrotherapy assessment?
- Document it as non-relevant since it is a common medication
- Record it and proceed normally
- Record it and require physician clearance before treatment (Correct answer)
- Omit it from records per HIPAA privacy rules
Correct answer: Record it and require physician clearance before treatment
Warfarin is an anticoagulant that increases bleeding risk; physician clearance should be obtained and documented before proceeding.
Question 4: Which section of the patient intake form is specifically designed to capture the reason the patient is seeking colonic hydrotherapy?
- Medical history
- Chief complaint / presenting concern (Correct answer)
- Medication log
- Lifestyle questionnaire
Correct answer: Chief complaint / presenting concern
The chief complaint or presenting concern section captures the primary reason the patient is seeking treatment in their own words.
Question 5: During a post-session assessment, a patient reports feeling lightheaded. What should the therapist document first?
- The exact volume of water used during the session
- Vital signs and onset time of the symptom (Correct answer)
- The patient's dietary habits from the past week
- The speculum size used during the session
Correct answer: Vital signs and onset time of the symptom
Vital signs and symptom onset time are the priority documentation items to assess and monitor for potential vasovagal or electrolyte-related reactions.
Question 6: Which SOAP note component is used to record the therapist's objective observations of the patient's abdomen during assessment?
- S — Subjective
- O — Objective (Correct answer)
- A — Assessment
- P — Plan
Correct answer: O — Objective
The Objective (O) section records measurable, observable findings such as abdominal palpation results, vital signs, and physical appearance.
Question 7: A patient discloses a history of Crohn's disease during intake. Which action is most appropriate?
- Proceed with a gentle session and monitor closely
- Document the disclosure and defer treatment pending physician approval (Correct answer)
- Advise the patient this condition is unrelated to colonic therapy
- Shorten the session to 20 minutes and proceed
Correct answer: Document the disclosure and defer treatment pending physician approval
Active or recent Crohn's disease is a contraindication; treatment should be deferred and physician clearance documented before proceeding.
CH Patient Assessment & Documentation 2
Which of the following findings during a pre-session abdominal assessment would be an absolute contraindication to proceeding with colonic hydrotherapy?