Deck 12: What Is Assessment Data and Why Is It Important

Question 1

Identify the statement that is NOT an appropriate assessment response.

A)The patient responded with a pain level of 7/10 prior to the treatment session.
B)The patient was able to button his sweater without any aids today.
C)The patient was able to ambulate over 20 feet today compared with 10 feet following last week's session.
D)The patient did not complain of any leg spasms during the treatment session today.

Answer 1

The patient responded with a pain level of 7/10 prior to the treatment session.

Question 2

Why is it important to provide sufficient information when writing assessment information in the SOAP note?

A)Another therapist can reproduce the treatment session if the first therapist is absent.
B)The reader can assess whether the plan of care is appropriate for the treatment needed by showing progress or regression.
C)The therapist can answer all of the patient's questions about each treatment session.
D)The patient can tell his or her family what the treatment session included.

Answer 2

The reader can assess whether the plan of care is appropriate for the treatment needed by showing progress or regression.

Question 3

Why is it important to provide documentation related to the patient's goals and outcomes?

A)It provides a clear picture of measurement of treatment ineffectiveness.
B)It helps the patient determine whether therapy is helping.
C)It provides the family with a measure of how the patient is progressing.
D)It helps third-party payers determine whether the patient is progressing.

Answer 3

It helps third-party payers determine whether the patient is progressing.

Question 4

Identify the correct assessment statement.

A)Patient demonstrated an antalgic gait pattern while walking into the TX session today.
B)Patient demonstrated frequent wt.shifts while sitting 15 min prior to TX.
C)Patient walked with a shuffling gait pattern with (R) hip in flexion.
D)Patient demonstrated a correct HEP today compared with needing VC last session.

Question 5

Identify the statement that would be included in the assessment section of the SOAP note.

A)The patient stated his pain level was a 5/10 prior to the treatment session.
B)The patient can now use his FWW to ambulate to his mailbox.
C)The patient was able to transfer from the bed to the w/c 2x with SBA last session.
D)The patient plans on seeing his doctor next week for a follow-up visit.

Question 6

Why is it important to summarize the patient's level of function in the assessment section of the SOAP note?

A)It helps determine how much pain the patient is experiencing.
B)It will help determine what services the patient needs.
C)This information is not necessary in the assessment section of the SOAP note.
D)It will help the therapist determine whether the patient is improving.

Question 7

What type of assessment information should be included in the initial evaluation completed by the PT?

A)Expected functional outcomes for the patient
B)Setting goals to improve the patient's level of function
C)Measurements of the patient's range of motion and muscle strength
D)The patient's ability to determine his pain level

Question 8

Identify the correct example of an anticipated goal that might be included in the assessment section.

A)Patient will walk with cane, min.(A) to bathroom in 3 weeks.
B)Patient states that he can get into and out of his car independently when driving.
C)Patient completed SLR exercises, 10x, 3 sets, supine, independently today.
D)Patient's husband wants her to be able to go out to dinner like they used to do.

Question 9

What is the purpose of the assessment section in SOAP note documentation?

A)It helps determine the level of pain the patient is experiencing.
B)It provides interpretation of the data content.
C)It sets the goals for future treatment sessions.
D)It develops the plan of care for treatment.

Question 10

It is important to identify a lack of progress in the treatment plan and for the PTA to make suggestions for changes.Identify the correct example of such a note.

A)There has been no change in sitting posture since the initial evaluation.PTA will speak with PT regarding change in plan of care.
B)Patient completed AROM in hip flex.to 90º as compared with initial evaluation of 120º.
C)Patient reported that his pain level has increased from the last session from 7/10 to 9/10.
D)Patient will be able to use quad cane to walk from house to mailbox by next session.

Question 11

In SOAP note documentation, what is the PT's documentation goal in the assessment section for the initial evaluation?

A)Evaluation of the patient's functional level
B)Interpretation of the patient's signs and symptoms
C)Assessment of the patient's ability to perform ADLs
D)Setting the initial goals in the plan of care

Question 12

In proper documentation of the assessment section of the SOAP note, it is important for the PTA to communicate changes in the plan of care.What statement best demonstrates this communication in the assessment section?

A)The patient met all short-term goals and will discuss setting new goals with PT.
B)The patient stated that his pain level was an 8/10 prior to treatment today.
C)The patient completed AROM in (L) shoulder, flex.(I) 10x, 3 sets.
D)The patient performed quad sets 10x, 3 sets.

Question 13

Identify an example of what could be an expected functional outcome.

A)The patient states that her pain level is decreasing with exercise.
B)The patient will make an appointment with the orthotist to reassess her brace.
C)The patient wants to be able to walk around independently in her home.
D)The patient can ambulate 20 feet with a quad cane and CGA.

Question 14

What type of data does the assessment section contain?

A)Data that can be reproduced or confirmed
B)Data that include what is going to happen
C)Data that contain the patient's medical history
D)Data that summarize the patient's subjective and objective information

Question 15

Identify the parameters that should be included in the assessment section of the SOAP note.

A)The patient's response to the last treatment session
B)Measurement comparisons from the initial evaluation and the current treatment session
C)The goals accomplished in the plan of care
D)Referral to another discipline, strength measurements, and stride length

Question 16

General assessment data provide a summary of the subjective and objective sections in the SOAP note.However, the student PTA often makes too general a statement that is not appropriate for this section.Identify the incorrect statement that the PTA might use for an assessment section.

A)Patient has made good progress and will ascend two steps by the third session.
B)Patient tolerated treatment well and the plan of care will continue.
C)Patient able to demonstrate increased PROM in all shoulder motions compared with last treatment.
D)Patient performed correct return demonstration of HEP today.

Question 17

Who is responsible for adapting or changing the goals during the treatment session when there is a lack of progress in the treatment plan?

A)PT and PTA
B)PT
C)Patient
D)PT and patient

Question 18

What is one of the most important concepts to address in the assessment section of the SOAP note for the PT?

A)Addressing the goals outlined in the initial evaluation
B)Adapting the goals and outcomes within the plan of care
C)Interpretation of the data
D)Continuing to focus on the past medical history

Question 19

The PTA has a specific responsibility when providing documentation in the assessment section of the SOAP note.What is the PTA's responsibility?

A)Determine when the goals have been met and discharge should be addressed
B)Communicate any recommended changes in the plan of care
C)Communicate any recommendations for additional services to the PT
D)Determine when the patient should receive additional services for speech

Question 20

What is the most important part of an outcome or goal in the assessment section?

A)Development of the plan of care
B)VRS for rating the level of pain in a body part
C)Measurable criteria demonstrating a change in function
D)Changes in girth measurements for all body parts, not just the part being treated