Question 1

Identify the statement below that is NOT an appropriate assessment response.

Accepted Answer

A)  The patient responded with a pain level of 7/10 prior to the treatment session. 
B)  The patient was able to button his sweater without any aids today. 
C)  The patient was able to ambulate over 20 feet today, as compared to 10 feet following last week's session. 
D)  The patient did not complain of any leg spasms during the treatment session today. 
A)  The patient responded with a pain level of 7/10 prior to the treatment session. 
B)  The patient was able to button his sweater without any aids today. 
C)  The patient was able to ambulate over 20 feet today, as compared to 10 feet following last week's session. 
D)  The patient did not complain of any leg spasms during the treatment session today. A

Question 2

Who is responsible for adapting or changing the goals during the treatment session when there is a lack of progress in the treatment plan?

Accepted Answer

A)  PT and PTA 
B)  PT 
C)  Patient 
D)  PT and patient 
A)  PT and PTA 
B)  PT 
C)  Patient 
D)  PT and patient B

Question 3

In proper documentation of the assessment section of the SOAP note, it is important for the PTA to communicate changes in the plan of care.What statement best demonstrates this communication in the assessment section?

Accepted Answer

A)  The patient met all short-term goals and will discuss setting new goals with PT. 
B)  The patient stated that his pain level was an 8/10 prior to treatment today. 
C)  The patient completed AROM in (L) shoulder, flex. (I) 10x, 3 sets. 
D)  The patient performed quad sets 10x, 3 sets. 
A)  The patient met all short-term goals and will discuss setting new goals with PT. 
B)  The patient stated that his pain level was an 8/10 prior to treatment today. 
C)  The patient completed AROM in (L) shoulder, flex. (I) 10x, 3 sets. 
D)  The patient performed quad sets 10x, 3 sets. A

Question 4

Identify an example of what could be an expected functional outcome from the examples listed.

Accepted Answer

A)  The patient states that her pain level is decreasing with exercise. 
B)  The patient will make an appointment with the orthotist to reassess her brace. 
C)  The patient wants to be able to walk around independently in her home. 
D)  The patient can ambulate 20 feet with a quad cane and CGA. 
A)  The patient states that her pain level is decreasing with exercise. 
B)  The patient will make an appointment with the orthotist to reassess her brace. 
C)  The patient wants to be able to walk around independently in her home. 
D)  The patient can ambulate 20 feet with a quad cane and CGA.

Question 5

What type of data does the assessment section contain?

Accepted Answer

A)  Data that can be reproduced or confirmed 
B)  Data that includes what is going to happen 
C)  Data that contains the patient's medical history 
D)  Data that summarizes the patient's subjective and objective information 
A)  Data that can be reproduced or confirmed 
B)  Data that includes what is going to happen 
C)  Data that contains the patient's medical history 
D)  Data that summarizes the patient's subjective and objective information

Question 6

What is one of the most important concepts to address in the assessment section of the SOAP note for the PT?

Accepted Answer

A)  Addressing the goals outlined in the initial evaluation 
B)  Adapting the goals and outcomes within the plan of care 
C)  Interpretation of the data 
D)  Continuing to focus on the past medical history 
A)  Addressing the goals outlined in the initial evaluation 
B)  Adapting the goals and outcomes within the plan of care 
C)  Interpretation of the data 
D)  Continuing to focus on the past medical history

Question 7

Identify the statement that would be included in the assessment section of the SOAP note.

Accepted Answer

A)  The patient stated his pain level was a 5/10 prior to the treatment session. 
B)  The patient can now use his FWW to ambulate to his mailbox. 
C)  The patient was able to transfer from the bed to the w/c 2x with SBA last session. 
D)  The patient plans on seeing his doctor next week for a follow-up visit. 
A)  The patient stated his pain level was a 5/10 prior to the treatment session. 
B)  The patient can now use his FWW to ambulate to his mailbox. 
C)  The patient was able to transfer from the bed to the w/c 2x with SBA last session. 
D)  The patient plans on seeing his doctor next week for a follow-up visit.

Question 8

What type of assessment information should be included in the initial evaluation completed by the PT?

Accepted Answer

A)  Expected functional outcomes for the patient 
B)  Setting goals to improve the patient's level of function 
C)  Measurements of the patient's range of motion and muscle strength 
D)  The patient's ability to determine his pain level 
A)  Expected functional outcomes for the patient 
B)  Setting goals to improve the patient's level of function 
C)  Measurements of the patient's range of motion and muscle strength 
D)  The patient's ability to determine his pain level

Question 9

What is the most important part of an outcome or goal in the assessment section?

Accepted Answer

A)  Development of the plan of care 
B)  VRS for rating the level of pain in a body part 
C)  Measurable criteria demonstrating a change in function 
D)  Changes in girth measurements for all body parts, not just the part being treated 
A)  Development of the plan of care 
B)  VRS for rating the level of pain in a body part 
C)  Measurable criteria demonstrating a change in function 
D)  Changes in girth measurements for all body parts, not just the part being treated

Question 10

General assessment data provide a summary of the subjective and objective sections in the SOAP note.However, the student PTA often makes too general a statement that is not appropriate for this section.Identify the incorrect statement that the PTA might use for an assessment section.

Accepted Answer

A)  Patient has made good progress and will ascend two steps by the third session. 
B)  Patient tolerated treatment well and the plan of care will continue. 
C)  Patient able to demonstrate increased PROM in all shoulder motions compared to last treatment. 
D)  Patient performed correct return demonstration of HEP today. 
A)  Patient has made good progress and will ascend two steps by the third session. 
B)  Patient tolerated treatment well and the plan of care will continue. 
C)  Patient able to demonstrate increased PROM in all shoulder motions compared to last treatment. 
D)  Patient performed correct return demonstration of HEP today.

Question 11

It is important to identify a lack of progress in the treatment plan and for the PTA to make suggestions for changes.Identify the correct example of such a note.

Accepted Answer

A)  There has been no change in sitting posture since the initial evaluation. PTA will speak with PT regarding change in plan of care. 
B)  Patient completed AROM in hip flex to 90º, as compared to initial evaluation of 120º. 
C)  Patient reported that his pain level has increased from the last session from 7/10 to 9/10. 
D)  Patient will be able to use quad cane to walk from house to mailbox by next session. 
A)  There has been no change in sitting posture since the initial evaluation. PTA will speak with PT regarding change in plan of care. 
B)  Patient completed AROM in hip flex to 90º, as compared to initial evaluation of 120º. 
C)  Patient reported that his pain level has increased from the last session from 7/10 to 9/10. 
D)  Patient will be able to use quad cane to walk from house to mailbox by next session.

Question 12

In SOAP note documentation, what is the PT's documentation goal in the assessment section for the initial evaluation?

Accepted Answer

A)  Evaluation of the patient's functional level 
B)  Interpretation of the patient's signs and symptoms 
C)  Assessment of the patient's ability to perform ADLs 
D)  Setting the initial goals in the plan of care 
A)  Evaluation of the patient's functional level 
B)  Interpretation of the patient's signs and symptoms 
C)  Assessment of the patient's ability to perform ADLs 
D)  Setting the initial goals in the plan of care

Question 13

Identify the parameters that should be included in the assessment section of the SOAP note.

Accepted Answer

A)  The patient's response to the last treatment session 
B)  Measurement comparisons from the initial evaluation and the current treatment session 
C)  The goals accomplished in the plan of care 
D)  Referral to another discipline, strength measurements, and stride length 
A)  The patient's response to the last treatment session 
B)  Measurement comparisons from the initial evaluation and the current treatment session 
C)  The goals accomplished in the plan of care 
D)  Referral to another discipline, strength measurements, and stride length

Question 14

Why is it important to summarize the patient's level of function in the assessment section of the SOAP note?

Accepted Answer

A)  It helps determine how much pain the patient is experiencing. 
B)  It will help determine what services the patient needs. 
C)  This information is not necessary in the assessment section of the SOAP note. 
D)  It will help the therapist determine if the patient is improving. 
A)  It helps determine how much pain the patient is experiencing. 
B)  It will help determine what services the patient needs. 
C)  This information is not necessary in the assessment section of the SOAP note. 
D)  It will help the therapist determine if the patient is improving.

Question 15

Identify the correct assessment statement from the list below.

Accepted Answer

A)  Patient demonstrated an antalgic gait pattern while walking into the tx session today. 
B)  Patient demonstrated frequent wt. shifts while sitting 15 min prior to tx. 
C)  Patient walked with a shuffling gait pattern with (R) hip in flexion. 
D)  Patient demonstrated a correct HEP today compared to needing vc last session. 
A)  Patient demonstrated an antalgic gait pattern while walking into the tx session today. 
B)  Patient demonstrated frequent wt. shifts while sitting 15 min prior to tx. 
C)  Patient walked with a shuffling gait pattern with (R) hip in flexion. 
D)  Patient demonstrated a correct HEP today compared to needing vc last session.

Question 16

What is the purpose of the assessment section in SOAP note documentation?

Accepted Answer

A)  It helps determine the level of pain the patient is experiencing. 
B)  It provides interpretation of the data content. 
C)  It sets the goals for future treatment sessions. 
D)  It develops the plan of care for treatment. 
A)  It helps determine the level of pain the patient is experiencing. 
B)  It provides interpretation of the data content. 
C)  It sets the goals for future treatment sessions. 
D)  It develops the plan of care for treatment.

Question 17

The PTA has a specific responsibility when providing documentation in the assessment section of the SOAP note.What is the PTA's responsibility?

Accepted Answer

A)  Determine when the goals have been met and discharge should be addressed 
B)  Communicate any recommended changes in the plan of care 
C)  Communicate any recommendations for additional services to the PT 
D)  Determine when the patient should receive additional services for speech 
A)  Determine when the goals have been met and discharge should be addressed 
B)  Communicate any recommended changes in the plan of care 
C)  Communicate any recommendations for additional services to the PT 
D)  Determine when the patient should receive additional services for speech

Question 18

Why is it important to provide documentation related to the patient's goals and outcomes?

Accepted Answer

A)  It provides a clear picture of measurement of treatment ineffectiveness. 
B)  It helps the patient determine if therapy is helping. 
C)  It provides the family with a measure of how the patient is progressing. 
D)  It helps third-party payers determine if the patient is progressing. 
A)  It provides a clear picture of measurement of treatment ineffectiveness. 
B)  It helps the patient determine if therapy is helping. 
C)  It provides the family with a measure of how the patient is progressing. 
D)  It helps third-party payers determine if the patient is progressing.

Question 19

Identify the correct example of an anticipated goal that might be included in the assessment section.

Accepted Answer

A)  Patient will walk with cane, min. (
A)  to bathroom in 3 weeks. 
B)  Patient states that he can get in and out of his car independently when driving. 
C)  Patient completed SLR exercises, 10x, 3 sets, supine, independently today. 
D)  Patient's husband wants her to be able to go out to dinner like they used to do. 
A)  Patient will walk with cane, min. (
A)  to bathroom in 3 weeks. 
B)  Patient states that he can get in and out of his car independently when driving. 
C)  Patient completed SLR exercises, 10x, 3 sets, supine, independently today. 
D)  Patient's husband wants her to be able to go out to dinner like they used to do.

Question 20

Why is it important to provide sufficient information when writing assessment information in the SOAP note?

Accepted Answer

A)  So another therapist can reproduce the treatment session if the first therapist is absent 
B)  So the reader can assess whether the plan of care is appropriate for the treatment needed, by showing progress or regression 
C)  So the therapist can answer all of the patient's questions about each treatment session 
D)  So the patient can tell his or her family what the treatment session included 
A)  So another therapist can reproduce the treatment session if the first therapist is absent 
B)  So the reader can assess whether the plan of care is appropriate for the treatment needed, by showing progress or regression 
C)  So the therapist can answer all of the patient's questions about each treatment session 
D)  So the patient can tell his or her family what the treatment session included

Identify the statement below that is NOT an appropriate assessment response.

Who is responsible for adapting or changing the goals during the treatment session when there is a lack of progress in the treatment plan?

In proper documentation of the assessment section of the SOAP note, it is important for the PTA to communicate changes in the plan of care.What statement best demonstrates this communication in the assessment section?

Identify an example of what could be an expected functional outcome from the examples listed.

What type of data does the assessment section contain?

What is one of the most important concepts to address in the assessment section of the SOAP note for the PT?

Identify the statement that would be included in the assessment section of the SOAP note.

What type of assessment information should be included in the initial evaluation completed by the PT?

What is the most important part of an outcome or goal in the assessment section?

General assessment data provide a summary of the subjective and objective sections in the SOAP note.However, the student PTA often makes too general a statement that is not appropriate for this section.Identify the incorrect statement that the PTA might use for an assessment section.

It is important to identify a lack of progress in the treatment plan and for the PTA to make suggestions for changes.Identify the correct example of such a note.

In SOAP note documentation, what is the PT's documentation goal in the assessment section for the initial evaluation?

Identify the parameters that should be included in the assessment section of the SOAP note.

Why is it important to summarize the patient's level of function in the assessment section of the SOAP note?

Identify the correct assessment statement from the list below.

What is the purpose of the assessment section in SOAP note documentation?

The PTA has a specific responsibility when providing documentation in the assessment section of the SOAP note.What is the PTA's responsibility?

Why is it important to provide documentation related to the patient's goals and outcomes?

Identify the correct example of an anticipated goal that might be included in the assessment section.

Why is it important to provide sufficient information when writing assessment information in the SOAP note?

Introduction to Documentation

The World Health Organization and the International Classification of Functioning, Disability and Health

Reimbursement Issues Related to Documentation

Documentation Content and Organization

Physical Therapy Patient Management and Documentation Responsibilities

What Is Subjective Data and Why Is It Important?

What Is Objective Data and Why Is It Important?

What Is the Plan and Why Is It Important?

Putting the Pieces of the Puzzle Together

How Does Documentation Relate to Patient Issues?

Your Documentation Related to Legal and Ethical Issues

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Exam 9: What Is Assessment Data and Why Is It Important?

Identify the statement below that is NOT an appropriate assessment response.

Who is responsible for adapting or changing the goals during the treatment session when there is a lack of progress in the treatment plan?

In proper documentation of the assessment section of the SOAP note, it is important for the PTA to communicate changes in the plan of care.What statement best demonstrates this communication in the assessment section?

Identify an example of what could be an expected functional outcome from the examples listed.

What type of data does the assessment section contain?

What is one of the most important concepts to address in the assessment section of the SOAP note for the PT?

Identify the statement that would be included in the assessment section of the SOAP note.

What type of assessment information should be included in the initial evaluation completed by the PT?

What is the most important part of an outcome or goal in the assessment section?

General assessment data provide a summary of the subjective and objective sections in the SOAP note.However, the student PTA often makes too general a statement that is not appropriate for this section.Identify the incorrect statement that the PTA might use for an assessment section.

It is important to identify a lack of progress in the treatment plan and for the PTA to make suggestions for changes.Identify the correct example of such a note.

In SOAP note documentation, what is the PT's documentation goal in the assessment section for the initial evaluation?

Identify the parameters that should be included in the assessment section of the SOAP note.

Why is it important to summarize the patient's level of function in the assessment section of the SOAP note?

Identify the correct assessment statement from the list below.

What is the purpose of the assessment section in SOAP note documentation?

The PTA has a specific responsibility when providing documentation in the assessment section of the SOAP note.What is the PTA's responsibility?

Why is it important to provide documentation related to the patient's goals and outcomes?

Identify the correct example of an anticipated goal that might be included in the assessment section.

Why is it important to provide sufficient information when writing assessment information in the SOAP note?

Introduction to Documentation

The World Health Organization and the International Classification of Functioning, Disability and Health

Reimbursement Issues Related to Documentation

Documentation Content and Organization

Physical Therapy Patient Management and Documentation Responsibilities

What Is Subjective Data and Why Is It Important?

What Is Objective Data and Why Is It Important?

What Is the Plan and Why Is It Important?

Putting the Pieces of the Puzzle Together

How Does Documentation Relate to Patient Issues?

Your Documentation Related to Legal and Ethical Issues

Filters