Documentation Chapters 1-3

Question 1

Disablement

Answer 1

The consequences that chronic or acute conditions have on the body and the person’s ability to act in a socially expected and personally desired way.

Question 2

Functioning

Answer 2

Umbrella Term, Includes all body functions, activities, and limitations.
Positive Ascpect

Question 3

Disability

Answer 3

Umbrella Term, Dysfunction at one or more impairments, activity limitation, and participation restriction
Negative aspect

Question 4

Body Functions

Answer 4

physiology of the body and psychological functions
(how everything works together)

Question 5

Body Structures

Answer 5

anatomy of body
(all the physical parts and pieces)

Question 6

Impairments

Answer 6

problems with body functions or structures

Question 7

Activity

Answer 7

functional tasks a person can do

Question 8

Activity Limitations

Answer 8

functional tasks a person CAN NOT do

Question 9

Participation

Answer 9

life roles a person can participate in

Question 10

Participation Restrictions

Answer 10

life roles a person CAN NOT participate in

Question 11

Contextual Factors

Answer 11

Factors that make up a person’s life, living, and background

Question 12

Environmental Factors

Answer 12

Physical, social, and attitudes the person lives and carries out their lives in
Like home, work, government, and country

Question 13

Personal Factors

Answer 13

Specific to the person and their background.
Like age, gender, race, childhood, and coping strategies.

Question 14

Difference between impairment, activity limitation, and participation restriction.

Answer 14

Impairment is a problem in the body’s function or structure like limited ROM.
Activity limitation is a task the person can not complete like brushing their hair.
Participation restriction is a life event a person can not take part in like the ability to work.

Question 15

Documentation

Answer 15

Any entry into the individual’s health record like consultation reports, initial examination reports, progress notes, summations of care, etc. that identifies the care the person received and their response to that care.

Question 16

Why is there a need for a common language in PT documentation?

Answer 16

If there was no common language in PT documentation there would be no common ground from specialty to specialty causing miscommunication between reimbursors and other health care providers. It would also be hard to read and apply EBPs to treatment.

Question 17

How can disablement concepts be integrated into PT documentation?

Answer 17

A PTA can incorporate disablement concepts into their documentation by including measures of impairments, limitations, or restrictions and describing how the impairment is involved in such limitations and restrictions. The PTA should also explain how the interventions are bringing change to the impairment, limitations, and restrictions.

Question 18

Examples of Participation restrictions

Answer 18

Going to school
Walking in the community
Going to the grocery store
Working

Question 19

Examples of Activity limitations

Answer 19

Taking a bath
Brushing teeth
Going up and down stairs
Turning a doorknob
Writing
Donning socks

Question 20

Examples of impairments

Answer 20

Limited ROM
Poor endurance
Poor balance

Question 21

How can a pt. access a PT for care

Answer 21

Patients can access physical therapy care by self-referral (depending on insurance and state regulations), referral from other health care professionals, hospitalization, home health services, and school-based services.

Question 22

6 Elements of Patient/Client Management Model

Answer 22

1. Examination
2. Evaluation
3. Diagnosis
4. Prognosis
5. Intervention
6. Outcomes

Question 23

Definition and Description of Examination

Answer 23

Process of collecting information and data on patient’s problems and why they are seeking PT.

Question 24

Definition and Description of Evaluation

Answer 24

Interpreting collected data and information as a whole to determine overall function, diagnosis, prognosis, POC, goals, duration of PT, and discontinuation plans.

Question 25

Definition and Description of Diagnosis

Answer 25

Label which describes dysfunction requiring PT interventions

Question 26

Definition and Description of Prognosis

Answer 26

Predicted level of improvement, treatment goals, expected outcomes, duration and frequency, and interventions to be used.

Question 27

Definition and Description of Intervention

Answer 27

Interaction of the PT or PTA to produce changes in condition by optimizing individual function.

Question 28

Definition and Description of Outcomes

Answer 28

tests and observations used to determine the patient's response to interventions and progress toward goals.

Question 29

Role of PT and PTA within the Patient/Client Management Model

Answer 29

PT- Examination, Evaluation, Diagnosis, Prognosis PTA and PT- Interventions and Outcomes

Question 30

PTA roles related to patient care, documentation, and communication

Answer 30

The PTA’s role in the physical therapy process falls within interventions and outcomes of the Patient/Client Management Model. A PTA can provide all 9 categories of interventions, use clinical reasoning to determine the readiness of patients for interventions, consult with PT, perform tests and document measures, and modify care within POC.

Question 31

9 Categories of Intervention

Answer 31

1. Patient instruction 2. Airway clearance techniques 3. AD 4. Biophysical agents 5. Functional training (activities and participation) 6. Integumentary repair and protection techniques 7. Manual therapy 8. Motor function training 9. Thera Ex.

Question 32

Essential components of POC

Answer 32

diagnosis goals interventions planned proposed frequency and duration discharge plans

Question 33

Major reasons to document

Answer 33

To track progress legal reasons research evidence insurance billing

Question 34

Types of patient data found in medical record

Answer 34

demographics diagnoses problem lists medications vital signs laboratory data

Question 35

How can clinical decision-making be shown in the medical record?

Answer 35

A clinician can integrate the clinical decision-making process by documenting changes in patient status to concurrent changes in plan or care or plan to discuss changes in status with PT to revise POC.

Question 36

Role of PTA in the clinical decision-making process

Answer 36

A PTA can assist in showing clinical decision-making by modifying interventions with POC and taking objective measures and comparing to the initial examination.

Question 37

Reasonable and necessary criteria

Answer 37

1. Must be a specific and effective treatment for the patient’s condition. 2. Level of complexity to be provided by PT or PTA. 3. The condition of the patient demonstrates the need for professional assistance. 4. The amount, frequency, and duration of the services must be reasonable.

Question 38

What is the difference between skilled care and maintenance care?

Answer 38

Skilled care is to complete a goal of improvement, but maintenance therapy is to help a patient stay at a current functional level and limit disease progression.

Question 39

How can you document pt. response to treatment?

Answer 39

PT or PTA should document any patient complaints or reported functional improvements under the subjective section of the documentation.

Question 40

Ethical obligations that pertain to documentation according to APTA

Answer 40

PTA shall ensure documentation accurately reflects the nature and extent of the service provided

Question 41

PTA's role in determining medical necessity

Answer 41

The PTA should report to PT if goals are met, are not being met promptly, and if interventions can be done without professional help to help determine medical necessity.

Question 42

How does prognosis influence the need for medically necessary skilled care?

Answer 42

If the patient’s prognosis, is they will not improve and function is the new normal then applying physical therapy in a skilled setting will not benefit the patient due to skilled therapy being tailored to improvement.