Quiz 2

Question 1

what is the purpose of the medical record?

Answer 1

complete and accurate recording of care

basis for planning and treatment

means of communication for attending healthcare professionals

description of patient services

verification of services for payers

data for health research

secondarily: education of staff, providers, and students; compliance and accreditation; research, policy making, industry,

Question 2

authentication of the medical record

Answer 2

date and signature of the attending PT

Question 3

utilization

Answer 3

an audit of care done on a practice to see if something is being over utilized compared to surrounding areas

fraud and abuse

medical malpractice

sometimes documentation wording will raise red flags for insurance companies

Question 4

reason for denial

Answer 4

if you get a denial, it is generally due to documentation error

billing doesn’t allow more than 5 ICD codes, so yours may be dropped bc nursing, OT, PT all put in their diagnoses=creates a reason for denial.

Question 5

general principles of documentation

Answer 5

need to be legible

errors are crossed out once and dated and initialed

timely documentation done immediately or after treatment

spelling and grammar are essential

abbreviations should come from standardized list

Question 6

WNL

Answer 6

w/in normal limits

Question 7

PMH

Answer 7

past medical history

Question 8

BID

Answer 8

twice a day

Question 9

MMT

Answer 9

manual muscle tests

Question 10

OA

Answer 10

osteoarthritis

Question 11

ROM

Answer 11

range of motion

Question 12

PROM

Answer 12

passive range of motion

Question 13

AROM

Answer 13

active range of motion

Question 14

WB

Answer 14

weight bearing

Question 15

WHO

Answer 15

world health organization

Question 16

HEP

Answer 16

home exercise program

Question 17

LE

Answer 17

lower extremity

Question 18

what is the disability model?

Answer 18

the framework for the Guide to PT Practice

categorizes the impact of medical conditions on function

4 categories

Question 19

what are the 4 categories of the disablement model?

Answer 19

pathology, impairment, functional limitation, and disability

Question 20

what is the ICF model and what does it involve?

Answer 20

standardized way of describing conditions

determine the health condition, what body functions/ structures/activities/ participation are affected, what the personal/environmental factors are, an d what the plan of care is

Question 21

what are the components of the patient/client model?

Answer 21

examination, evaluation, diagnosis, prognosis, and intervention

Question 22

what is the examination?

Answer 22

collection of data

screening and performing tests and measures

Question 23

what is the evaluation?

Answer 23

synthesizing data from the examination leads to diagnosis, prognosis, and plan for intervention

clinical decision making

Question 24

what is the diagnosis?

Answer 24

relates to the impairment to function and the patient problem list

Question 25

what is the prognosis?

Answer 25

potential for improvement poor, fair, good, or excellent need to be at least fair to get to rehab hospital

Question 26

what is the intervention?

Answer 26

what the PT decides to do based on their eval, exam, diagnosis, and prognosis

Question 27

what is a progress note?

Answer 27

notes subjective and objective changes in the patient's status recorded weekly (about every 7-10 days) home health may be done every 30 days or after the 14th visit

Question 28

what is a reassessment note?

Answer 28

gathering subjective and objective data based on what was collected on the initial visit document any progress being made recorded monthly (every 30 days) some insurances may require it every 2 weeks instead of monthly

Question 29

what is a discharge note?

Answer 29

patient's final subjective and objective status compares the initial and discharge data shows the patient has met their goals needed if a patient stops showing up to PT

Question 30

SOAP note

Answer 30

subjective: what the patient, family member, or significant other says the patient feels or is doing, only as relevant to this episode of care objective: what the PT performs/observes/inspects in a reproducible manner relative to the episode of care assessment: analysis for the s/s; creates a picture of where the patient is today; DON'T RELIST THE OBJECTIVE DATA plan: treatment developed to meet the goals or objectives

Question 31

subjective info

Answer 31

chief complaint-main reason for seeking medical attention history of present illnesses (onset, location, frequency, duration, severity, and quality of symptoms) past medical history review of systems (systematic injury into patient's general health and organ systems) OLD CARTS

Question 32

OLD CARTS

Answer 32

Onset Location Duration Character Alleviating/Aggravating factors Radiation Temporal pattern (time of day) Severity

Question 33

objective info

Answer 33

balance and baseline tests no interpretation, just test result-can be bulleted reflects what the PT performs, observes, or inspects in a reproducible manner vitals, assessments, tests and measures, treatments, equipment, procedures, direction/patient education

Question 34

what is the assessment?

Answer 34

assesses the patient's progress through a systematic analysis of the problem, possible interaction, and status changes DO NOT REPEAT OBJECTIVE DATA identify problems based on subjective and objective info (listed in order of importance) provide reasoning and evidence

Question 35

SMART goals

Answer 35

specific, measure able, attainable, realistic, and time-bound

Question 36

functional outcomes

Answer 36

associated with patient's daily activities (ability to return to sports for example)

Question 37

what are the 2 types of goals?

Answer 37

body structure/function activity

Question 38

what is a body structure/function goal?

Answer 38

patient will improve [power, strength, sensory integration] as evidenced by an increase in [test & measurement] to allow for [ activity/participation , e.g. PSFS, outcome measure] in time frame​

Question 39

what is an activity goal?

Answer 39

patient will improve [an limitation in activity e.g. maintaining static balance, walking level surfaces] as evidenced by an increase in [test & measurement, e.g. gait velocity] to allow for [participation, e.g. PSFS, measures] in time frame​

Question 40

how long are short-term goals?

Answer 40

0-14 days 0-3 months

Question 41

how long are long-term goals?

Answer 41

30-60 days 3-6 months

Question 42

what is included in defensible documentation?

Answer 42

identification of the person description of the movement/activity a connection of the movement/activity to a specific function specific conditions in which the activity will be performed factors for measuring the outcome time frame for achieving the goal

Question 43

what factors influence outcome?

Answer 43

co-morbidities, conmittent diagnosis, complexities, and complicating factors

Question 44

what are some possible reasons for a claim denial?

Answer 44

inadequate information billing did not match documentation goals did not match the problems or diagnosis patient did not require the skills of a physical therapist potential for improvement is not identified need for skilled therapy is not identified it is really maintenance therapy provided

Question 45

when is a treatment medically necessary?

Answer 45

when the treatment is of such sophistication or complexity and/or the patient is a complexity of that, and if the treatment can only be safely and effectively performed by a licensed PT or PTA under the direct supervision of a therapist in a private practice setting

Question 46

medical necessity

Answer 46

patient need the PT demonstrates that the treatment is supported by evidenced based practice, clinical reasoning and judgment and that without treatment there is little expectancy for the patient to improve