Question 1

Is it possible for the supervising PT to be subpoenaed by the prosecution and the PTA to be subpoenaed by the defense?

Accepted Answer

A) No, the PT supervises the PTA and that can never happen. 
B) Yes, if the PTA's notes are not complete, one side could decide the PTA would be more appropriate for them than the supervising PT. 
C) Yes, if the two sides can determine that one person would be more appropriate for their side. 
D) No, all of the records for the patient were completed by the PTA, with the supervising PT reviewing them on a regular basis, and both must testify for the same side. 
A) No, the PT supervises the PTA and that can never happen. 
B) Yes, if the PTA's notes are not complete, one side could decide the PTA would be more appropriate for them than the supervising PT. 
C) Yes, if the two sides can determine that one person would be more appropriate for their side. 
D) No, all of the records for the patient were completed by the PTA, with the supervising PT reviewing them on a regular basis, and both must testify for the same side. C

Question 2

An incident is anything that happens to a patient, employee, or visitor that is "out of the ordinary." Which incident could be appropriate for a legal action?

Accepted Answer

A) The patient fell off the step when leaving the clinic and broke her leg. 
B) The patient stated he slipped on the ice in front of his home and hurt his back. 
C) The patient fell today, but was able to catch herself on her bed. 
D) The patient's daughter reported that her mother fell getting out of the bed today. 
A) The patient fell off the step when leaving the clinic and broke her leg. 
B) The patient stated he slipped on the ice in front of his home and hurt his back. 
C) The patient fell today, but was able to catch herself on her bed. 
D) The patient's daughter reported that her mother fell getting out of the bed today. A

Question 3

What is important for the PTA to consider regarding appropriate documentation?

Accepted Answer

A) Documentation completed by the PTA could become part of a court case in a legal proceeding. 
B) Documentation completed by the PTA is under the supervision of the PT and will not be allowed into a legal proceeding. 
C) It is important to ensure that the PTA is who he or she claims to be and that the PTA can sign such a document. 
D) It is important for the PTA to document what is done, but he or she does not have to worry whether it is always accurate. 
A) Documentation completed by the PTA could become part of a court case in a legal proceeding. 
B) Documentation completed by the PTA is under the supervision of the PT and will not be allowed into a legal proceeding. 
C) It is important to ensure that the PTA is who he or she claims to be and that the PTA can sign such a document. 
D) It is important for the PTA to document what is done, but he or she does not have to worry whether it is always accurate. A

Question 4

How long must medical records be kept so you can testify in court?

Accepted Answer

A) 1 year 
B) 2 years 
C) 3 years 
D) 4 years 
A) 1 year 
B) 2 years 
C) 3 years 
D) 4 years

Question 5

In proper documentation, which SOAP note section would be most important to ensure accuracy?

Accepted Answer

A) The assessment section would be the most important because it documents the summary of the objective and subjective sections. 
B) The subjective section would be most important because it documents the patient's responses to treatment. 
C) The objective section would be most important because it documents the patient's progress within the plan of care. 
D) The plan section would be the most important because it documents the plan outlined for the patient's care. 
A) The assessment section would be the most important because it documents the summary of the objective and subjective sections. 
B) The subjective section would be most important because it documents the patient's responses to treatment. 
C) The objective section would be most important because it documents the patient's progress within the plan of care. 
D) The plan section would be the most important because it documents the plan outlined for the patient's care.

Question 6

When is it legal to use blue ink in written documentation?

Accepted Answer

A) You can use it for signatures and for other parts of the document you want to delineate or emphasize from another part and to determine which document has an original signature. 
B) You can use blue ink when the document does not have to be copied or reproduced. 
C) It is never legal to use blue ink in written documentation. 
D) You can use blue ink in written documentation if it will not be used in a legal proceeding. 
A) You can use it for signatures and for other parts of the document you want to delineate or emphasize from another part and to determine which document has an original signature. 
B) You can use blue ink when the document does not have to be copied or reproduced. 
C) It is never legal to use blue ink in written documentation. 
D) You can use blue ink in written documentation if it will not be used in a legal proceeding.

Question 7

Why does the PTA need to protect the patient's confidentiality in a legal proceeding?

Accepted Answer

A) It is required by HIPAA guidelines and is the responsibility of the treating PTA. 
B) HIPAA guidelines do not apply because it is a legal proceeding. 
C) In a legal proceeding, HIPAA guidelines are assumed. 
D) The PTA does not need to follow HIPAA guidelines because the lawyer will do so. 
A) It is required by HIPAA guidelines and is the responsibility of the treating PTA. 
B) HIPAA guidelines do not apply because it is a legal proceeding. 
C) In a legal proceeding, HIPAA guidelines are assumed. 
D) The PTA does not need to follow HIPAA guidelines because the lawyer will do so.

Question 8

When testifying in court, how can the PTA protect the patient?

Accepted Answer

A) By ensuring that the documentation is short and to the point, without a lot of extra information included 
B) By making sure the documentation is rewritten prior to the trial, so it is correct 
C) By determining which records given to the attorney would be most beneficial to the patient 
D) By demonstrating that informed consent was received from the patient before treating the patient. 
A) By ensuring that the documentation is short and to the point, without a lot of extra information included 
B) By making sure the documentation is rewritten prior to the trial, so it is correct 
C) By determining which records given to the attorney would be most beneficial to the patient 
D) By demonstrating that informed consent was received from the patient before treating the patient.

Question 9

A patient in a nursing home refused treatment.The PTA treated the patient anyway and lied about the patient's response.Could there be legal action?

Accepted Answer

A) Yes, the patient refused; the PTA should not have performed the treatment and should not have documented the refusal. 
B) No, the patient was in a nursing home and was not competent to make such a decision. 
C) Yes, if the PTA lied and the patient is competent to make that decision, the PTA should not have treated the patient and should have documented the refusal. 
D) No, the patient's family can refuse treatment, not the patient. 
A) Yes, the patient refused; the PTA should not have performed the treatment and should not have documented the refusal. 
B) No, the patient was in a nursing home and was not competent to make such a decision. 
C) Yes, if the PTA lied and the patient is competent to make that decision, the PTA should not have treated the patient and should have documented the refusal. 
D) No, the patient's family can refuse treatment, not the patient.

Question 10

You have been given a subpoena to appear in court.What does that mean?

Accepted Answer

A) This legal document requires you to present yourself to the court at the date, time, and place stated in the document. 
B) This is a legal document that states you can come to court when your schedule allows. 
C) A subpoena is a legal document that requires you to testify but does not require that you go to court. 
D) This is not a legal document and you do not have to respond to it. 
A) This legal document requires you to present yourself to the court at the date, time, and place stated in the document. 
B) This is a legal document that states you can come to court when your schedule allows. 
C) A subpoena is a legal document that requires you to testify but does not require that you go to court. 
D) This is not a legal document and you do not have to respond to it.

Question 11

If you are asked under oath to disclose your medical facility's yearly income, what would you do?

Accepted Answer

A) State that the information is in the computer and you can retrieve it later. 
B) Tell the lawyer that information is none of his business and has no bearing on the case. 
C) Make up a figure and hope it is correct. 
D) Because this is information you would not usually know, you would simply state, "I don't know." 
A) State that the information is in the computer and you can retrieve it later. 
B) Tell the lawyer that information is none of his business and has no bearing on the case. 
C) Make up a figure and hope it is correct. 
D) Because this is information you would not usually know, you would simply state, "I don't know."

Question 12

What is the purpose of the prosecution in a court proceeding?

Accepted Answer

A) Determines who is guilty in a court proceeding 
B) Is responsible for determining the sentence passed 
C) Is responsible for presenting the case against an entity accused of breaking the law or causing injury to someone 
D) Is responsible for presenting the case and assessing the monetary judgment against the defense 
A) Determines who is guilty in a court proceeding 
B) Is responsible for determining the sentence passed 
C) Is responsible for presenting the case against an entity accused of breaking the law or causing injury to someone 
D) Is responsible for presenting the case and assessing the monetary judgment against the defense

Question 13

What does the phrase patient confidentiality mean to the PTA?

Accepted Answer

A) Any medical person working in that facility can access the patient's records. 
B) The patient and the patient's family have access to the medical records. 
C) Anyone directly treating the patient can access the patient's medical records. 
D) Only the physician and the therapist have access to the medical records. 
A) Any medical person working in that facility can access the patient's records. 
B) The patient and the patient's family have access to the medical records. 
C) Anyone directly treating the patient can access the patient's medical records. 
D) Only the physician and the therapist have access to the medical records.

Question 14

When filing an incident report, what is the time frame in which it should be completed?

Accepted Answer

A) Within 8 hours of the incident 
B) Within 12 hours of the incident 
C) Within 24 hours of the incident 
D) Within 2 weeks of the incident 
A) Within 8 hours of the incident 
B) Within 12 hours of the incident 
C) Within 24 hours of the incident 
D) Within 2 weeks of the incident

Question 15

What is a common mistake the PTA may make when testifying in court?

Accepted Answer

A) Telling the truth and nothing but the truth 
B) Reporting just the facts and only the facts 
C) Giving too much information regarding a question that was asked 
D) Answering the questions asked by the defense attorney 
A) Telling the truth and nothing but the truth 
B) Reporting just the facts and only the facts 
C) Giving too much information regarding a question that was asked 
D) Answering the questions asked by the defense attorney

Question 16

During a court proceeding, it is discovered that you included an incident report in the patient's chart.The attorney questions your actions.How would you respond?

Accepted Answer

A) "I forgot where I was supposed to put it." 
B) "I put it there because I did not have time to take it to risk management." 
C) "I don't agree with the facility that it should go to risk management, so I put it in the patient's file." 
D) "I did not follow the protocol at my facility and should have given it to the risk management office." 
A) "I forgot where I was supposed to put it." 
B) "I put it there because I did not have time to take it to risk management." 
C) "I don't agree with the facility that it should go to risk management, so I put it in the patient's file." 
D) "I did not follow the protocol at my facility and should have given it to the risk management office."

Question 17

Legal proceedings take multiple forms.Identify the term that matches the definition: This proceeding does not occur in a courtroom, both lawyers are present, and a court reporter or tape recorder is used.

Accepted Answer

A) Statement 
B) Deposition 
C) Court 
D) Ethical report 
A) Statement 
B) Deposition 
C) Court 
D) Ethical report

Question 18

There are several ways to falsify documentation.Identify the correct example.

Accepted Answer

A) Ensuring that all documentation is correct before it is completed 
B) Having the supervising PT review all notes for accuracy 
C) Changing a document without a dated amendment 
D) Using ink to document patient care so you cannot erase your mistakes 
A) Ensuring that all documentation is correct before it is completed 
B) Having the supervising PT review all notes for accuracy 
C) Changing a document without a dated amendment 
D) Using ink to document patient care so you cannot erase your mistakes

Question 19

What is the purpose of the defense in a court proceeding?

Accepted Answer

A) Protects an individual or group from a wrongful lawsuit brought without cause 
B) Ensures that someone conducting business in an illegal manner does not harm an individual or group 
C) Helps to make sure the court proceeding is equal for all participants 
D) Ensures that the defendant is not bullied 
A) Protects an individual or group from a wrongful lawsuit brought without cause 
B) Ensures that someone conducting business in an illegal manner does not harm an individual or group 
C) Helps to make sure the court proceeding is equal for all participants 
D) Ensures that the defendant is not bullied

Question 20

Identify the statement that would be appropriate for a legal proceeding and would be included in the patient's file.

Accepted Answer

A) The patient had a traumatic amputation and was given a new prosthesis. 
B) The patient came to therapy today with his dog. 
C) The patient fell out of bed today and cut his head. 
D) The patient's AROM was WNL following the last treatment session. 
A) The patient had a traumatic amputation and was given a new prosthesis. 
B) The patient came to therapy today with his dog. 
C) The patient fell out of bed today and cut his head. 
D) The patient's AROM was WNL following the last treatment session.

Is it possible for the supervising PT to be subpoenaed by the prosecution and the PTA to be subpoenaed by the defense?

An incident is anything that happens to a patient, employee, or visitor that is "out of the ordinary." Which incident could be appropriate for a legal action?

What is important for the PTA to consider regarding appropriate documentation?

How long must medical records be kept so you can testify in court?

In proper documentation, which SOAP note section would be most important to ensure accuracy?

When is it legal to use blue ink in written documentation?

Why does the PTA need to protect the patient's confidentiality in a legal proceeding?

When testifying in court, how can the PTA protect the patient?

A patient in a nursing home refused treatment.The PTA treated the patient anyway and lied about the patient's response.Could there be legal action?

You have been given a subpoena to appear in court.What does that mean?

If you are asked under oath to disclose your medical facility's yearly income, what would you do?

What is the purpose of the prosecution in a court proceeding?

What does the phrase patient confidentiality mean to the PTA?

When filing an incident report, what is the time frame in which it should be completed?

What is a common mistake the PTA may make when testifying in court?

During a court proceeding, it is discovered that you included an incident report in the patient's chart.The attorney questions your actions.How would you respond?

Legal proceedings take multiple forms.Identify the term that matches the definition: This proceeding does not occur in a courtroom, both lawyers are present, and a court reporter or tape recorder is used.

There are several ways to falsify documentation.Identify the correct example.

What is the purpose of the defense in a court proceeding?

Identify the statement that would be appropriate for a legal proceeding and would be included in the patient's file.

Introduction to Documentation

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

Demystifying the Icd-10 Coding System

Reimbursement Issues Related to Documentation

Documentation Content and Organization

Physical Therapy Patient Management and Documentation Responsibilities

How Does Documentation Relate to Patient Issues

Introduction to the Soap Note

What Is Subjective Data and Why Is It Important

What Is Objective Data and Why Is It Important

What Is Assessment Data and Why Is It Important

What Is the Plan and Why Is It Important

Putting the Pieces Together

Filters

Exam 8: Legal and Ethical Issues Related to Documentation

Is it possible for the supervising PT to be subpoenaed by the prosecution and the PTA to be subpoenaed by the defense?

An incident is anything that happens to a patient, employee, or visitor that is "out of the ordinary." Which incident could be appropriate for a legal action?

What is important for the PTA to consider regarding appropriate documentation?

How long must medical records be kept so you can testify in court?

In proper documentation, which SOAP note section would be most important to ensure accuracy?

When is it legal to use blue ink in written documentation?

Why does the PTA need to protect the patient's confidentiality in a legal proceeding?

When testifying in court, how can the PTA protect the patient?

A patient in a nursing home refused treatment.The PTA treated the patient anyway and lied about the patient's response.Could there be legal action?

You have been given a subpoena to appear in court.What does that mean?

If you are asked under oath to disclose your medical facility's yearly income, what would you do?

What is the purpose of the prosecution in a court proceeding?

What does the phrase patient confidentiality mean to the PTA?

When filing an incident report, what is the time frame in which it should be completed?

What is a common mistake the PTA may make when testifying in court?

During a court proceeding, it is discovered that you included an incident report in the patient's chart.The attorney questions your actions.How would you respond?

Legal proceedings take multiple forms.Identify the term that matches the definition: This proceeding does not occur in a courtroom, both lawyers are present, and a court reporter or tape recorder is used.

There are several ways to falsify documentation.Identify the correct example.

What is the purpose of the defense in a court proceeding?

Identify the statement that would be appropriate for a legal proceeding and would be included in the patient's file.

Introduction to Documentation

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

Demystifying the Icd-10 Coding System

Reimbursement Issues Related to Documentation

Documentation Content and Organization

Physical Therapy Patient Management and Documentation Responsibilities

How Does Documentation Relate to Patient Issues

Introduction to the Soap Note

What Is Subjective Data and Why Is It Important

What Is Objective Data and Why Is It Important

What Is Assessment Data and Why Is It Important

What Is the Plan and Why Is It Important

Putting the Pieces Together

Filters