Documentation

Question 1

ICF model

Answer 1

relating findings to functional limitations

Question 2

SBAR format

Answer 2

used in acute care
situation
background
assessment
reccomendation

Question 3

SOMR

Answer 3

used in acute care
Source oriented medical record
each discipline has its own section in chart
all of pt’s problem may not be recognized by each discipline

Question 4

POMR

Answer 4

Seen in acute care
Problem oriented medical record
center around pt’s problems
all disciplines contribute and recognize all of pt’s problems

Question 5

SOAP

Answer 5

daily treatment note
Subjective
Objective
Assessment
Plan

Question 6

Guide Format

Answer 6

Outpatient and Rehab
Initial Exam consisting of:
Examination
Assessment/Evaluation
Diagnosis
Prognosis
Goals
Plan
Intervention

Question 7

“Guide”
Examination

Answer 7

tests and measures

Question 8

“Guide”
Assessment

Answer 8

Summative statement
Medical diagnosis
PT diagnosis
Prognosis

Question 9

Summary statement of the assessment

Answer 9

introductory sentence should briefly describe the pt and summarize the background information

Question 10

Diagnosis statement of the assessment

Answer 10

state the medical Dx/differential diagnosis or health condition along with further classification
add stage of recovery
may need to present an alternative to the referring diagnosis w/ rationale

Question 11

PT Diagnosis of the assessment

Answer 11

document a brief summary of the pt’s impairments and link impairments to activity limitation or participation restriction

Question 12

PT Diagnosis of assessment examples

Answer 12

eg: leg muscle weakness causing inability to stand up to go to bathroom, shoulder ROM reduction impacting ability to dress w/o compensation

Question 13

Prognosis of Assessment

Answer 13

potential to benefit from pt
conclude w/ a statement summarizing pt’s potential to benefit from PT and the reasons why treatment is or is not indicated
may also include comorbidities that could impact PT

Question 14

Expected outcomes

Answer 14

long term goals

Question 15

Anticipated Goals

Answer 15

Short term goals

Question 16

ICF terminology:
Body Functions

Question 17

ICF terminology:
Body Structures

Question 18

ICF terminology:
Impairments

Question 19

ICF terminology:
Activity

Question 20

ICF terminology:
Participation

Question 21

ICF terminology:
Activity limitations

Question 22

ICF terminology:
Participation restrictions

Question 23

ICF terminology:
Environmental Factors

Question 24

SMART Goal

Answer 24

Specific
Measurable
Assignable
Realistic
Time-bound

Question 25

SMART Goal Specific

Answer 25

target a specific area for improvement

Question 26

SMART Goal Measurable

Answer 26

use quantifiable measures as indicators of progress

Question 27

SMART Goal Assignable

Answer 27

able to specify who will complete task

Question 28

SMART Goal Realistic

Answer 28

can be achieved with the current resources

Question 29

SMART Goal Time-bound

Answer 29

to to achieve goal is specificed

Question 30

Participation goal

Answer 30

express expected outcomes in terms of specific roles in which the pt wishes to participate

Question 31

Activity goals

Answer 31

express expected outcomes in terms of skills needed to participate in necessary or desired roles

Question 32

Impairment goals

Answer 32

express expected outcomes in terms of specific impairments in body structures or functions that contribute to the functional limitations

Question 33

Plan

Answer 33

state the proposed frequency and duration of physical therapy visits in addition to a tentative date or re-evaluation

Question 34

Plans should also include:

Answer 34

interventions, communications, referrals, instruction

Question 35

Document consent of a plan

Answer 35

CYA "the findings of this evaluation were discussed with [name of patient/responsible party] and he/she consented to the above plan of care"

Question 36

Intervention

Answer 36

Purposeful and skilled interaction of the physical therapist with the patient/client and other individuals involved in the care of the patient/client, along with the treatment methods to produce changes

Question 37

Discharge plan

Answer 37

When a pt reaches their goals or reaches maximal medical improvement

Question 38

correcting errors

Answer 38

use black ink put line through error write (error) above mistake, date it, initial it

Question 39

verbal orders

Answer 39

document date/time/order with name that gave order and your signature must be entered in chart

Question 40

signing documentation

Answer 40

legal name, PT, highest earned academic degree after bachelor's in alphabetical order, other credentials

Question 41

Delegation to a PTA

Answer 41

they can write their own notes, but must be signed by you (the PT)

Question 42

Referring to yourself in notes

Answer 42

do not use "i", but third person

Question 43

Malpractice major element 1

Answer 43

The PT owed the pt a duty of care

Question 44

Malpractice major element 2

Answer 44

The PT breached that duty of care

Question 45

Malpractice major element 3

Answer 45

The pt was injured and suffered harm

Question 46

Malpractice major element 4

Answer 46

The injury came about as a result of the PT's breach of duty of care

Question 47

Types of Damages

Answer 47

Economic Damages Non-Economic damages Punitive

Question 48

Locality rule

Question 49

Majority rule

Question 50

Release of patient records