Deck 13: Your Documentation Related to Legal and Ethical Issues

Question 1

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

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.

Answer 1

This legal document requires you to present yourself to the court at the date, time, and place stated in the document.

Question 2

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 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.

Answer 2

Anyone directly treating the patient can access the patient's medical records.

Question 3

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

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.

Answer 3

It is required by HIPAA guidelines and is the responsibility of the treating PTA.

Question 4

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

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.

Question 5

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

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

Question 6

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

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 they do not have to worry if it is always accurate.

Question 7

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

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 8

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

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

Question 9

When testifying in court, how can the PTA protect 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 10

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

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.

Question 11

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

A) State that the information is in the computer and you can get it for him 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 a common mistake the PTA may make when testifying in court?

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 13

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?

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 14

Legal proceedings take multiple forms.Identify the word 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.

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

Question 15

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

A) Protects an individual or group from a wrongful lawsuit 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 16

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

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 17

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?

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.

Question 18

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

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 19

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

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 20

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

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