Deck 5: Documentation Content and Organization

Question 1

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

A)Functional limitation
B)Medical diagnosis
C)Physical therapy diagnosis
D)Disability

Answer 1

Physical therapy diagnosis

Question 2

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:

A)informed consent.
B)an incident report.
C)a confidentiality consent.
D)permission to treat.

Answer 2

informed consent.

Question 3

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

A)When providing information to the occupational therapist regarding the patient's goals
B)When providing information to a physician regarding the patient's progress
C)When providing information to a nurse regarding the patient's vital signs
D)When providing information to the speech therapist regarding the patient's posture

Answer 3

When providing information to a physician regarding the patient's progress

Question 4

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?

A)It is very complicated to use and does not provide specific parameters related to patient care.
B)It is simple to use and provides the PTA with a concise checklist for the treatment given.
C)It provides an organized checklist for treatment but is not patient specific.
D)It provides a concise checklist for treatment but does not give specific parameters related to patient care.

Question 5

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?

A)POMR
B)SOAP
C)FOR
D)SOMR

Question 6

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."

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

Question 7

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

A)POMR
B)SOAP
C)FOR
D)SOMR

Question 8

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

A)PCP
B)DEP
C)SOAP
D)HIPAA

Question 9

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

A)POMR
B)SOAP
C)FOR
D)SOMR

Question 10

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

A)Information related to the patient's problem requiring medical treatment
B)Information related to the patient's ability to pay for treatment
C)Information related to the patient's living conditions
D)Information related to the patient's ability to speak English

Question 11

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

A)POMR
B)SOAP
C)FOR
D)SOMR

Question 12

In what type of setting would you use an IEP?

A)A hospital
B)An inpatient rehabilitation facility
C)An outpatient clinic
D)A school

Question 13

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."

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

Question 14

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

A)SOAP
B)PSP
C)PSPG
D)DEP

Question 15

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

A)POMR
B)SOAP
C)FOR
D)SOMR

Question 16

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?

A)SOAP notes
B)PSP notes
C)PSPG notes
D)DEP notes

Question 17

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

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

Question 18

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

A)POMR
B)SOAP
C)FOR
D)SOMR

Question 19

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

A)Systems approach
B)Disease process approach
C)Problem-solving approach
D)Time process approach

Question 20

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

A)Physician
B)PTA
C)PT
D)Social worker