*2.PTA 200-Documentation

Question 1

What are 2 models of disability presented in our text?

Answer 1

NAGI and ICF (International Classification of Functioning, Disablility and Health

Question 2

What are the 4 aspects of Nagi’s model of disability?

Answer 2

Pathology, Impairment, Functional Limitation, and Disability

Question 3

moving in bed, transferring from one surface to another, rising from a chair, ambulating, dressing, bathing, etc

Answer 3

ADL

Question 4

community ambulation activities, such as going to the grocery store, bank or restaurant

Answer 4

IADL (I= Instrumental)

Question 5

refers to the inability to engage in age-specific, gender-specific, or sex-specific roles in a particular social context and physical environment. UNIVERSAL AND RELATES TO PATIENTS ROLE IN SOCIETY

Answer 5

Disability

Question 6

Any entry into the patient-client record, such as a(n) consultation report, initial examination report, progress note, flow sheet/checklist, that identifies the care/service provided, re-examination, or summation of care.”

Answer 6

Documentation

Question 7

Of the agencies listed, which ones carry the weight of regulation and legal penalty if not followed?

Answer 7

ICF

Question 8

what are the reasons we document?

Answer 8

1. Create legal documents (ethical and legal responsibility)
2. Record patient data- throughout the entire episode of care enabling Outcome Assessment Measures. Example FIM scoring on page 85.
3. Record patient care – interventions, turning schedules, response to treatment, etc.
4. Provide proof that your care is reasonable and necessary and skilled. (pg 12) Skilled care being of utmost importance.
5. Demonstrate the clinical decision making process. PTAs contribute by always relating intervention to POC goals.
6. Reimbursement Justification

Question 9

How many times a particular sequence is repeated

Answer 9

Frequency

Question 10

How long a particular sequence will take place

Answer 10

Duration

Question 11

What are the types of documentation?

Answer 11

Narrative, POMR, SOAP, and FOR. Refer to power point for this, she is SUPER confusing. (pages 6,7, and 8) you can edit this if you understand it. lol

Question 12

Is the PT, PTA or both responsible for the initial evaluation?

Answer 12

PT

Question 13

Is the PT, PTA or both responsible for the re-evaluation/re-assessment?

Answer 13

PT

Question 14

Pr

Answer 14

Problem

Question 15

S

Answer 15

Subjective

Question 16

PT’s COMPLAINT OF PAIN related specifically to the goals and area of treatment

Answer 16

Subjective

Question 17

O

Answer 17

Objective

Question 18

A

Answer 18

Assessment (refer to pg 12 and 13 on power point)

Question 19

P

Answer 19

Plan

Question 20

5 Elements of pt/client model of the PT Process

Answer 20

Examination
Evaluation
Physical Therapy Diagnosis
Prognosis
INTERVENTION

Question 21

Before 1960, what was the definition of health?

Answer 21

free or absent from disease