Deck 12: How Does Documentation Relate to Patient Issues?

Question 1

To determine the necessity of treatment, the PTA can use functional outcomes or limitations.Identify the correct definition for a functional outcome.

A) Those that include the discharge plan
B) Those related only to the patient's ability to progress
C) Those related to the patient's prior level of function
D) Those related to the patient's medical information

Answer 1

Those related to the patient's prior level of function

Question 2

What is an example of a third-party payer?

A) HMO
B) CMS
C) Medicare
D) PPO

Answer 2

HMO

Question 3

Identify the patient who would receive physical therapy in the educational setting.

A) A patient who cannot push his or her wheelchair (I)
B) A patient with fetal alcohol syndrome (FAS) who cannot communicate without a communication board
C) A patient with Down syndrome who cannot walk (I)
D) A patient with cerebral palsy (CP) who can walk (I)

Answer 3

A patient with Down syndrome who cannot walk (I)

Question 4

What does the phrase patient confidentiality mean to the PTA?

A) Any medical person working in that facility can access the patient's records.
B) The patient and his or her 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 treating therapist have access to the medical records.

Question 5

From the descriptions given, identify the patient who could no longer receive physical therapy because it would be considered maintenance therapy.

A) The patient did not make measurable progress this certification period.
B) The patient's active range of motion (AROM) increased by 15 degrees this past certification period.
C) The patient can walk (I) within her house but not to the mailbox.
D) The patient can transfer (I) from the bed to the wheelchair.

Question 6

There are several ways to correct a mistake made during the documentation process.Identify the incorrect method.

A) Draw a single line through an error and date and initial above it.
B) Draw a horizontal line through empty spaces.
C) Write using pencil, so you can erase errors.
D) Complete documentation using a blue pen.

Question 7

Identify the statement that would be appropriate communication related to the patient.

A) "I noticed that the patient you were treating should be referred to OT. What is his diagnosis?"
B) "I wanted to know what is wrong with your patient, Mr. Smith, because I am his Aunt."
C) "Your patient, Mrs. Jones, has an appointment next week with the neurologist," stated the receptionist.
D) "I saw my neighbor in your clinic and wanted to know why you are seeing him."

Question 8

It is important for the treating PTA to protect the patient in multiple ways.What is NOT an appropriate protection?

A) Use of appropriate equipment
B) Proper use of an incident report
C) Legal responsibilities of the treating PTA
D) No informed consent

Question 9

Identify the statement that would indicate physical therapy.

A) The patient had a traumatic amputation and will be fitted for prosthesis next week.
B) The patient cannot speak or understand the spoken word.
C) The patient was involved in a motor vehicle accident (MVA) and was diagnosed with a C6 spinal cord injury (SCI).
D) The patient had a (R) cerebrovascular accident (CVA) and can no longer walk independently.

Question 10

Treatment provided by a PT/PTA must meet several requirements.What are they?

A) Treatment must be medically or educationally appropriate.
B) Treatment must be covered by insurance and the patient.
C) Treatment must be appropriate and referred by the primary care physician.
D) Treatment must be covered by the patient and referred by the family physician.

Question 11

When attempting to treat a patient, the patient has the right to refuse treatment.Which statement would be an example of such a refusal?

A) The patient completed therapy and then stated she did not want to do any exercises today.
B) The patient took her pain medication 5 minutes before treatment and wants you to wait.
C) The patient refused treatment today, stating she was too tired.
D) The patient wants you to come back in 30 minutes, after her bath, to treat her.

Question 12

Identify the statement below that would NOT be included in an incident report.

A) Mr. Jacques fell off the mat and hurt his knee.
B) Mrs. Watson hit her head on the cabinet when getting up from the plinth.
C) Mr. Jones tripped on the footstool and fell down in the clinic today.
D) Mrs. Smith slipped getting off of the plinth but did not fall down.

Question 13

Identify the correct reason for the provision of physical therapy in an educational setting.

A) The patient cannot push her wheelchair from the classroom to the other side of campus, 1,000 ft.
B) The patient cannot walk from the classroom to the lunchroom (I).
C) The patient is now able to walk more than 100 feet today as compared to 10 feet following the last IEP.
D) The patient has not had any leg spasms since last week.

Question 14

When filing an incident report, where should it be placed for review?

A) In the patient's chart
B) In the physical therapy administration office
C) In a separate file with risk management
D) In the physician's patient file

Question 15

What would be an appropriate statement to include in an incident report?

A) The PTA reported to the PT that the patient fell today and injured her shoulder when she hit the floor.
B) The patient missed the chair while sitting down, but he did not fall to the floor.
C) The patient reported that the PTA stopped him from falling off the bed today.
D) The PTA reported that the nursing staff "dropped" the patient onto the mat from standing without injury to the patient.

Question 16

Identify the appropriate color of ink that is used predominately in legal documentation.

A) Black
B) Purple
C) Red
D) Green

Question 17

An incident is anything that happens to a patient, employee, or visitor that is "out of the ordinary." Which statement would require an incident report?

A) The patient received a first degree burn to her arm but did not complain of any pain.
B) The patient stated he slipped on the ice in front of his house and hurt his back.
C) The patient fell at home today but was able to catch herself on the mat.
D) The patient's daughter reported her mother fell getting out of the car today.

Question 18

Under the HIPAA Act of 1996, what safeguard should be initiated to protect the patient?

A) Ensure that computer programs are not password protected.
B) Always leave filing cabinets with patient information unlocked.
C) Conduct conversations related to the patient in a conference room or hallway.
D) Never discuss the patient by name in a public room, hallway, or elevator.

Question 19

When taking verbal information related to the patient by phone, it is important to provide all of the following except:

A) the time and date of the call.
B) a statement regarding the emotional state of the patient.
C) the patient's entire medical history.
D) the name of the PTA taking the information.

Question 20

Which action reflects an appropriate type of communication?

A) Taking verbal phone referrals for physical therapy from another health care provider
B) Providing medical information to another therapist who is not seeing the patient
C) Providing information to the patient's neighbor
D) Telling the patient's aide information about the patient's progress