Exam 5: Documentation Content and Organization

Under what circumstances might a PT or PTA use a letter format when providing documentation about a treatment session?

Of the four types of documentation included in Chapter 5, which one does NOT include "plan" in its content?

What practitioner is responsible for providing the therapy evaluation of the patient prior to the treatment session?

The majority of content organization models use a specific approach to arrange information.Identify the correct method most commonly used in documentation.

In what type of setting would you use an IEP?

Prior to receiving treatment from a PT, the patient is given information regarding the treatment process and the right to refuse treatment.This information process is known as:

Medical records are often organized following specific formats.Which type of format is organized around the identification and treatment of the patient's problems?

Which type of format is often criticized because it takes too much time to read through each section for information?

Different formats are often used in documentation.One type uses computerized documentation.However, this type of documentation can be problematic for the PTA.Why would this type of documentation cause a problem?

Which type of medical record format uses a structured approach for reporting function and outcome?

Which documentation method includes a plan section as part of the note?

Identify the term that is defined as "a restriction of the ability to perform."

Which type of format is organized around the medical services offered in the clinical facility?

Identify the term that is defined by the "inability to engage in age-specific, gender-specific or sex-specific roles in a particular social context and physical environment."

Which type of medical record organization uses an outline format to document what happens during the patient treatment session?

Documentation content can be grouped into six categories.Identify one of the correct categories.

Which type of format is organized so that the various disciplines have the ability to review the problem and treatment necessary for the patient from ONE place in the medical record?

There are multiple methods used to document care given to patients related to physical therapy treatment.What method uses a problem, status, and plan review?

Identify the term that is defined as the "abnormalities or dysfunctions of the bones, joints, ligaments, muscles, tendons, nerves, and skin, or problems with movement resulting from an injury to or abnormality of the brain, spinal cord, or pulmonary or cardiovascular systems."

Identification of pathokinesiologic problems associated with faulty biomechanical or neuromuscular action is the definition of which of the following terms?