記錄一次處理

一次紀錄由不適紀錄、觀察、觸感三個基礎構成。本文一步一步示範如何新增一次紀錄，從不適紀錄到身體圖與動態觀察。

記錄的目標不是填滿所有欄位，而是保留足夠資訊，讓下次回顧時能快速掌握上次的個案狀態與處理內容。一次紀錄由三個基礎構成：

不適紀錄：個案這次不舒服的地方與描述。 觀察：在身體圖標記姿勢與部位狀況，以及動態觀察。 觸感：觸診時手下的質地與個案反應（見 記錄觸感與感受）。

你可以依實際觀察填寫，不需要每個欄位都完成。本文示範前兩個基礎；觸感另見專文。

以下畫面以示範個案「承恩」操作。實際使用時，請先在「個案」分頁打開你要記錄的個案。

第一部分：開始一次紀錄

1. 在「個案」分頁打開個案，按頁面最底部的「新增評估紀錄」。

!在個案頁底部點新增評估紀錄

第二部分：不適紀錄

2. 紀錄頁會開在「基本」分頁。在「不適紀錄」區塊按「新增」，記下個案不舒服的地方（可新增多筆）。

!在基本分頁的不適紀錄區塊點新增

3. 先選「部位」（必填），可從頭頸、軀幹、上肢、下肢中挑一個。

!在新增不適視窗選擇部位

4. 接著可記錄這個部位的「感覺」（緊／痠／痛…）、不適自評，以及什麼動作會誘發、多久以前、外部原因等。填好後點右上角「儲存」。

!填寫感覺、不適自評與誘發動作等

「什麼動作會誘發」會依部位給不同的常見選項；不需要每項都填，以實際問到的為主。

5. 該筆不適會列在「不適紀錄」裡。整體、不分部位的狀況可寫在「整體補充」，最下方還可評「整體不適」。

!不適紀錄列出該筆紀錄

第三部分：在身體圖標記觀察

6. 點上方「觀察」分頁，預設顯示「正面」身體圖。直接點身體上有狀況的部位。

!切到觀察分頁，點身體部位

7. 在該部位的選項裡點一下膠囊切換嚴重度（輕 → 中 → 明顯 → 取消），完成後點右上角「完成」。

!在部位選項點選並切換嚴重度

嚴重度會以顏色呈現：未選為白、輕為綠、中為黃、明顯為紅。同一個部位再點一次會進入編輯，不會新增為第二筆。

8. 回到身體圖，標記過的部位會依嚴重度上色，下方「已記錄」也會列出這次的觀察。可切換「背面／左側面／右側面」記錄其他面向。

!標記後身體圖會依嚴重度上色

第四部分：動態觀察與存檔

9. 點「動態觀察」分頁，可記錄站姿旋轉、單腳站、深蹲等動作的觀察。以實際觀察到的為主。

!動態觀察分頁的動作清單

10. 都記錄好後，點右上角「完成」存檔。下次打開這位個案，這次的內容會接在時間線上。

!點右上角完成存檔

接下來

第三個基礎「觸感」請看 記錄觸感與感受。 完成一次處理紀錄後，可以進一步使用 復盤 比較處理前後的變化。

How to record a session

A record is built from three foundations — discomfort log, observations, and sensation. This page walks through adding a record step by step, from the discomfort log to the body map and movement observation.

The goal of recording isn't to fill every field — it's to keep enough so that next time you can quickly recall the client's state and what you did. A record is built from three foundations:

Discomfort log — where the client is uncomfortable, and how they describe it. Observations — marking posture and regions on the body map, plus movement observation. Sensation — what you feel under-hand while palpating, and how the client responds (see Recording touch & sensation).

Fill in what you actually observed; nothing is required. This page covers the first two foundations; sensation has its own page.

The screens below use the demo client "承恩". In real use, open the client you want to record from the Clients tab first.

Part 1: Start a record

1. Open a client from the Clients tab, then tap "New evaluation" at the very bottom of the page.

!Tap New evaluation at the bottom of the client page

Part 2: Discomfort log

2. The record opens on the "Basic" tab. In the "Discomfort log" section, tap "Add" to note where the client is uncomfortable (add as many as needed).

!Tap Add in the Discomfort log section

3. First pick the "Region" (required) — choose one from head/neck, trunk, upper limb, or lower limb.

!Choose a region in the New discomfort sheet

4. Then record the "Feeling" for that region (tight / sore / aching…), a self-rating, plus what movements trigger it, how long ago it started, and external causes. Tap "Save" at the top right when done.

!Fill the feeling, self-rating, and triggering movements

"What movements trigger it" offers region-specific suggestions; fill only what you actually learned.

5. The entry is listed under "Discomfort log". Whole-body notes that aren't region-specific go in "Overall notes", and you can rate "Overall discomfort" at the bottom.

!The discomfort log lists the entry

Part 3: Mark observations on the body map

6. Tap the "Observations" tab at the top; it shows the "Front" body figure. Tap the region where you noticed something.

!Switch to Observations, tap a region

7. Tap an option capsule to cycle its severity (mild → moderate → marked → off), then tap "Done" at the top right.

!Pick an option and cycle its severity

Severity shows as colour: white = unselected, green = mild, yellow = moderate, red = marked. Tapping the same region again opens it for editing — it won't create a second entry.

8. Back on the body map, marked regions are coloured by severity, and the "Recorded" list below shows this session's observations. Switch to "Back / Left side / Right side" to record other planes.

!Marked regions are coloured by severity

Part 4: Movement observation and saving

9. Tap the "Dynamic" tab to record movement observations such as standing rotation, single-leg stance, and squat.

!The movement list under the Dynamic tab

10. When done, tap "Done" at the top right to save. Next time you open this client, this session sits on the timeline.

!Tap Done at the top right to save

Next

The third foundation, sensation, is covered in Recording touch & sensation. After a session record, use Debrief to compare before and after.