PT Documentation Responsibilities Chapter 5 6e Exam Prep

Chapter 5. Physical Therapy Patient Management and Documentation Responsibilities

Multiple Choice

1. According to the APTA’s Guide to Physical Therapist Practice, there are five elements of physical therapy patient management. What is the first step that should be completed in this process?

A. Examination

B. Evaluation

C. Diagnosis

D. Intervention

2. When the patient is ready for the discharge process, who is responsible for discharge from physical therapy services?

A. Primary care physician

B. Nursing supervisor

C. PT

D. PTA

3. When the PT performs the evaluation of the patient, what would be the most important factor to consider related to the evaluation process?

A. Functional abilities

B. Cognitive abilities

C. Communication abilities

D. Quality of movement

4. What information would be included in the subjective section of the SOAP note when the PT completes the initial evaluation?

A. Referral to another medical practitioner

B. Active range of motion (AROM) parameters

C. The patient’s progress

D. Pain level prior to treatment

5. It is important to use appropriate terminology when referring to the patient in the documentation process. This process is known as “person-first terminology.” Identify the correct statement that meets the requirements of person-first terminology.

A. The paralyzed patient, Mr. Jones, was able to walk 20 feet today.

B. The CVA patient was doing better today.

C. Mrs. Smith, who has a left transtibial amputation, is getting her prosthesis today.

D. The TBI male in room 603 was combative today and needed to be moved.

6. The patient’s medical record includes, but is not limited to, 11 sections. Choose the section that is usually not included in the medical record.

A. History

B. Plan of care

C. Tests and measures

D. Parent’s occupation

7. Within the component section of the evaluation, the PT looks at the patient’s tone. How does tone affect the outcome of the evaluation?

A. Changes in tone can make the patient fatigue much more quickly.

B. Changes in tone can affect the patient’s functional abilities.

C. Changes in tone can affect the patient’s ability to think.

D. Changes in tone do not affect the patient’s ability to walk.

8. A judgment about the level of optimal improvement the patient may attain and the amount of time needed to reach that level is the definition of:

A. evaluation.

B. intervention.

C. examination.

D. prognosis.

9. Choose the item that would not be included in the section of the initial examination process that reviews the patient’s history.

A. Social history

B. Medications

C. Goals and outcomes

D. Functional status

10. The anticipated discharge plans would be part of what section within the initial evaluation completed by the PT?

A. Plan of care

B. Prognosis

C. Tests and measures

D. Systems review

11. Why is it important to know the patient’s pain level prior to the treatment session?

A. To determine whether the patient needs pain medication.

B. To determine whether the patient cannot perform the exercises that day.

C. To determine whether the patient has increased or decreased pain following the treatment session

D. It has no bearing on the treatment session.

12. The ability of patients to catch themselves if they lose their balance or their center of gravity shifts too far in one direction is defined as:

A. abnormal reflex patterns.

B. automatic reactions.

C. autonomic reactions.

D. abnormal postural changes.

13. Evaluating the ability of the patient to move in a smooth, coordinated manner as he or she transitions in and out of a position is known as evaluating:

A. cognitive abilities.

B. normal reflex patterns.

C. motor planning.

D. quality of movement.

14. How can a PT or PTA determine a patient’s cognitive level?

A. By asking questions related to person, place, and thing

B. By asking questions related to the weather, time of day, and the person’s gender

C. By asking questions about the person’s prior level of function

D. By asking questions about the person’s name, occupation, and educational level

15. What helps determine the type of documentation used when treating a patient?

A. Patient’s diagnosis

B. Type of setting

C. The plan of care

D. The third-party payer

16. What does the diagnosis help the PT determine during the evaluation process?

A. Ability of the patient to progress through the plan of care

B. Amount of support that will be provided by the patient’s family

C. Impact on the patient’s ability to learn and communicate

D. Impairments and functional limitations of the patient

17. In which portion of the PT note would completion of the therapeutic goals be included?

A. Subjective data

B. Summation of care

C. Plan of care

D. Initial evaluation

18. Documentation responsibilities are shared by the PT and the PTA. Identify the responsibility that the PTA may complete within his or her scope of practice.

A. Discharge summary

B. Initial evaluation

C. Progress note

D. Changes to plan of care

19. The PT has asked the PTA to perform an initial evaluation on a patient, stating, “You have watched me do evaluations for over 2 years now and I think you are ready to do this one. I will watch you, make changes to it, and sign it when you are finished.” What would be the appropriate course of action for the PTA?

A. Tell the PT that the evaluation is not within the PTA’s scope of practice and refuse to complete it.

B. Tell the PT that, as a PTA, he or she only feels comfortable doing the objective section of the evaluation.

C. Complete the evaluation and have the PT review it and sign it.

D. Report the PT to his or her supervisor.

20. Why is it important to document reasons for skilled therapeutic intervention in the initial evaluation?

A. To help the patient learn what activities are important for his or her return to work

B. To provide the caregiver or family with a home exercise program

C. To provide evidence to third-party payers that PT services are necessary

D. To prove to the treating facility that PT services are needed