Sim hom lus nug

Yuav txiav txim lus nug txog ntaub ntawv thiab kev sau li cas

Lus nug sau ntaub ntawv sim kev hais lus tshaj lij: yam twg yuav tsum sau, yam twg yog kev txiav txim ntawm tus kheej, thiab ntaub ntawv twg yuav tsum ceev zais thiab khaws kom raug.

Hom lus nug tseem ceeb Kwv yees 4 feeb 2026-06-24
Lus qhia ua ntej nyeem zaj

Lub ntsiab ntawm lus nug sau ntaub ntawv

Siv ob peb feeb xub txais moj khaum txiav txim ntawm zaj no, ces nyeem ntsiab lus thiab lus piav qauv lus nug.

  • Sau yam tus neeg tau txais kev pab hais, yam pom, yam tau ua, thiab nws txoj kev teb
  • Tsis txhob sau kev kuaj mob, kev txiav txim raws siab ntsws, lossis ntaub ntawv ntiag tug uas tsis cuam tshuam
  • Ntaub ntawv yuav tsum meej, objective, raws sijhawm, thiab raws kev ceev lus zais
01

Kev sau ntaub ntawv tsis yog sau kev xav

Kev xeem feem ntau cais objective note, subjective feedback, assessment, thiab plan.

Ntaub ntawv raug yuav tsum objective li ntau tau thiab tsis sau tus kws zaws kev kwv yees ua qhov tseeb.

02

Kev ceev ntiag tug thiab kev raug yog tseem ceeb tib yam

Ntaub ntawv tus neeg tau txais kev pab yog ntaub ntawv rhiab; tsis txhob muab faib lam tau lam ua.

Yog nug kev tu ntaub ntawv, xub xaiv qhov meej, raug, ceev zais, thiab raws txheej txheem.

Kev qhia qauv lus nug
03

Qauv lus nug

Which note is most appropriate for a client record?

  1. Client was difficult and probably has a serious disease.
  2. Client reported right shoulder discomfort before the session.
  3. Client needs medical treatment from the therapist.
  4. Client's condition is not important to document.
Lo lus teb: B

Lus piav：B yog ntaub ntawv objective dua txog tus neeg tau txais kev pab cov lus. Lwm qhov muaj kev kuaj mob, txiav txim raws siab ntsws, lossis tsis quav ntsej kev sau.

04

Cov lus sau ntaub ntawv

Nkag siab cov lus no ua ntej ces nqe lus nug thiab lus piav tom ntej yuav txiav txim yooj yim dua.

SOAP
Moj khaum sau ntaub ntawv nquag: Subjective, Objective, Assessment, Plan.
objective
Kev soj ntsuam objective lossis qhov tseeb uas sau tau.
confidential
Kev ceev lus zais; txhob muab ntaub ntawv tus neeg tau txais kev pab tshaj tawm lam tau lam ua.
Rub App

Muab hom lus nug no tso rau hauv App kom xyaum txuas ntxiv

Zaj nyeem pab nkag siab txoj kev txiav txim; App haum rau xyaum txhua hnub, nyeem lus piav, rov xyuas lus nug yuam kev, thiab npaj lub sijhawm kawg.

  • Kev xyaum lub txhab lus nug raws tshooj
  • Lus piav Hmoob sib piv
  • Rov xyuas lus nug teb yuam kev tau nws
Siv xov tooj luam code qhib nplooj rubNrhiav qhov nkag iOS / Android tau nws

Kauj ruam tom ntej saib tau ntxiv

Saib hom lus nug, lus piav, thiab cai ntxiv nyob rau tib ncauj lus npaj xeem kom tsim moj khaum txiav txim puv dua.

Hom lus nug tseem ceeb Yuav txiav txim lus nug yam txwv tsis pub zaws li cas Siv lus Hmoob nkag siab MBLEx cov lus nug yam txwv tsis pub zaws, cov lus pheej hmoo, qauv piav, thiab txheej teb; xyaum pom thaum twg yuav zam, hloov, lossis xa mus.
Hom lus nug tseem ceeb Hom lus nug ciam kev coj ncaj ncees uas pom nquag Nkag siab cov lus nug nquag hauv MBLEx txog kev coj ncaj ncees thiab ciam haujlwm, nrog kev kuaj mob, kev ceev ntiag tug, kev sib txuas lus, kev sau ntaub ntawv, thiab kev xa mus. Hom lus nug tseem ceeb Yuav nyeem lus nug anatomy txog kev txav li cas Siv MBLEx cov qauv lus nug nkag siab flexion, extension, abduction, supination thiab lwm cov lus txuas rau haujlwm leeg nqaij li cas. Hom lus nug tseem ceeb Lus nug txiav txim xwm txheej tus neeg tau txais kev pab Nkag siab tias MBLEx cov lus nug xwm txheej tus neeg tau txais kev pab sim kev sib txuas lus, yam txwv tsis pub zaws, hloov kev pab, sau ntaub ntawv, thiab kev xa mus li cas. Hom lus nug tseem ceeb Yuav txiav txim lus nug informed consent li cas Kawm MBLEx informed consent: thaum twg yuav piav, txheeb, nres, lossis hloov phiaj xwm zaws.