Exam 1: Introduction to Documentation

Direct access allows PTs to practice with autonomy because it is understood that PTs recognize their legal responsibilities.What is this legal responsibility called?

What type of access allows a patient to see a PT without a physician's referral?

Documentation must meet today's standards for reimbursement and provides the basis for research.What two standards must be met for reimbursement to be successful?

Which taxonomy can be defined as the loss or abnormality of a physiological, psychological, or anatomical structure or function?

In the SOAP note example provided in Figure 1-1, why was the objective section incorrect?

What is the name of the accrediting agency for rehabilitation facilities?

Documentation classification has evolved over many years.Which documentation classification provides a definitive summary of an active pathology with the relationship to the resulting impairment?

What is the focus of outcomes in patient care related to PT and PTA documentation?

What is the website for the American Physical Therapy Association (APTA)?

Which two goals must physical therapy meet for the PT to receive reimbursement for services?

Why is documentation necessary in patient care?

What is the definition of documentation?

What state became the first state to allow direct access?

What is the former name of the accrediting agency for hospitals?

In the SOAP note example provided in Figure 1-1, why is the assessment section incorrect?

When was the first academic program developed for the PTA?

To provide high-quality medical care, the PT and PTA must demonstrate one exceptional skill.What is that one skill?

During which time period did documentation change, requiring more specific information?

What specific piece of legislation was responsible for changing the documentation process?

What two events changed treatment and documentation responsibilities for the PT and PTA?