Deck 1: Introduction to Documentation

Question 1

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

A) It is correct and no changes are necessary.
B) It needs to include more specific goals for rolling and sitting.
C) It needs to delineate how long the patient sat, compared to the last session.
D) It is correct but should also include the short-term goal of rolling.

Answer 1

It needs to delineate how long the patient sat, compared to the last session.

Question 2

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

A) Public Law 504
B) The American Disabilities Act
C) The Rehabilitation Act
D) The Health Insurance for the Aged and Disabled Act

Answer 2

The Health Insurance for the Aged and Disabled Act

Question 3

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?

A) Measures functional outcomes and identifies effective and efficient treatment
B) Describes functional activities that demonstrate appropriate interventions
C) Identifies appropriate interventions based on the type of treatments
D) Demonstrates effective and efficient treatment

Answer 3

Measures functional outcomes and identifies effective and efficient treatment

Question 4

What state became the first state to allow direct access?

A) California
B) Nebraska
C) Maryland
D) New York

Question 5

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

A) www.apta.us.net
B) www.apta.org
C) www.apta.com
D) www.apta.us.com

Question 6

What is the definition of documentation?

A) Anything written without supplying evidence
B) The use of documentary evidence to support original written work
C) Classifying knowledge that is not readily available
D) The assembling of documents without classification of knowledge

Question 7

When was the first academic program developed for the PTA?

A) 1959
B) 1967
C) 1973
D) 1979

Question 8

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

A) Medicare insurance and physician referrals
B) Medicaid insurance and types of documentation
C) HMO and physician referrals
D) Medicare insurance and types of documentation

Question 9

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

A) It did not report how much assistance was given in sitting and rolling, and could not be followed.
B) It did not report how long the patient was able to sit, but rolling is a skill that can be understood without further clarification.
C) It did not report how many times the patient rolled, but sitting can only be done in one position.
D) It did not report the specific parameters of the treatment session and was not reproducible.

Question 10

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

A) Inefficient and disorganized
B) Efficient and organized
C) Effective and efficient
D) Organized and effective

Question 11

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

A) Mid-1950s
B) Mid-1960s
C) Mid-1970s
D) Mid-1980s

Question 12

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

A) Scope of practice
B) Legal responsibilities
C) Ethical issues
D) Code of ethics

Question 13

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

A) Indirect
B) Express
C) Timely
D) Direct

Question 14

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

A) The ability to provide cost-effective care for the patient
B) The ability to provide efficient care for the patient
C) The ability to improve functional abilities of the patient
D) The ability to document appropriate patient care

Question 15

What is the name of the accrediting agency for hospitals?

A) CARF
B) CAPTE
C) JCAHO
D) HIPPA

Question 16

Why is documentation necessary in patient care?

A) It helps provide written and legal proof that treatment occurred.
B) It does not need to be written if it is reported verbally.
C) It helps determine what one might do with a patient.
D) It is not necessary at all.

Question 17

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?

A) ICIDH Classification
B) National Center for Medical Rehabilitation Research
C) Nagi Disablement Model
D) Functional Impairment Model

Question 18

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

A) Writing
B) Organization
C) Treatment
D) Communication

Question 19

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

A) Disability
B) Functional Limitation
C) Handicap
D) Impairment

Question 20

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

A) CARF
B) CAPTE
C) JCAHO
D) HIPPA