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(2) Musculoskeletal Examination > S1_L1: Documentation in PT > Flashcards

S1_L1: Documentation in PT Flashcards

1
Q

TRUE OR FALSE: Medical jargons are used in creating a concise documentation.

A

False

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2
Q

TRUE OR FALSE: All the positive findings are written before the negative findings in a concise documentation.

A

True

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3
Q

TRUE OR FALSE: Person-first language and abbreviations of medical terminologies are used in writing a concise documentation.

A

True

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4
Q

TRUE OR FALSE: Correcting an error in documentation is done by striking through the error, then writing “error” above it followed by the correct finding, signature, and date.

A

True

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5
Q

TRUE OR FALSE: Degrees and certification are important in the legibility of documentation.

A

True

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6
Q

TRUE OR FALSE: The Source-Oriented Medical Record-Keeping System (SOMR) is the more commonly used format of documentation.

A

False, it is the Subjective Objective Assessment Plan (SOAP).

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7
Q

TRUE OR FALSE: In documentation, leaving blank spaces is avoided.

A

True

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8
Q

TRUE OR FALSE: The progress notes are only done during the first PT session.

A

False, it’s initial evaluation

  • Progress notes are written after every PT session
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9
Q

TRUE OR FALSE: The initial evaluation notes are done before the patient goes back to MD for re-evaluation.

A

False, it’s re-evaluation notes

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10
Q

TRUE OR FALSE: The discharge notes / summary is done after the MD says patient achieved pre-injury level or is highly functional and therefore, can be discharged from PT.

A

True

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11
Q

Determine the corresponding descriptions of the subjective headings

  1. Accompanying illness, previous PT treatment
  2. Occupation, hobbies, vices
  3. Tests, labs, meds, rx related to the present complaint
  4. Architectural barriers, home set-up, furniture, distance, type of walking surfaces
  5. Includes pain, weakness, difficulty in moving, numbness, pins and needles sensation, and limited ROM of arm/neck/leg
  6. Family support, social support

A. Demographics
B. Chief Complaint (CC or c/o)
C. History of Present Illness (HPI)
D. Past Medical History (PMHx)
E. Lifestyle
F. Physical Environment
G. Social Environment
H. Patient’s Goal

A
  1. D
  2. E
  3. C
  4. F
  5. B
  6. G
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12
Q

Determine the corresponding subheading of the subjective findings

  1. Pt reported to fall on the floor c extended legs in a split position
  2. Hobby is dancing which he does q weekend
  3. Inability to walk & weight bear on (L) LE
  4. Denies any Hx of trauma, surgical operation, & hospitalization in the past.
  5. Lives c family in a 2-storey house c stairs ~15 steps c handrail on (B) sides.

A. Demographics
B. Chief Complaint (CC or c/o)
C. History of Present Illness (HPI)
D. Past Medical History (PMHx)
E. Lifestyle
F. Physical & Social Environment
G. Patient’s Goal

A
  1. C
  2. E
  3. B
  4. D
  5. F
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13
Q

Determine the corresponding subheading of the subjective findings

  1. Non-smoker & non-alcoholic beverage drinker
  2. To be able to walk again properly
  3. 22 y/o (-) Htn/DM, (R) handed ♂
  4. Pt was transported to Makati Medical Center through ambulance & underwent x-ray & MRI revealing (L) pulled hamstring
  5. X-ray showed (-) fx

A. Demographics
B. Chief Complaint (CC or c/o)
C. History of Present Illness (HPI)
D. Past Medical History (PMHx)
E. Lifestyle
F. Physical Environment
G. Social Environment
H. Patient’s Goal

A
  1. E
  2. H
  3. A
  4. C
  5. C
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14
Q

Determine the corresponding descriptions of the palpation grading

  1. Pain and wincing
  2. Refuses to be touched
  3. Pain
  4. Pain, wincing, and withdrawal

A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4

A
  1. B
  2. D
  3. A
  4. C
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15
Q

TRUE OR FALSE: Past Medical History does concern the present condition of the patient.

A

False

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16
Q

TRUE OR FALSE: Endomorph describes a lean body, that of a physically active individual.

A

False, it’s mesomorph

17
Q

TRUE OR FALSE: Muscle tone, crepitations, tightness, muscle spasm, muscle guarding, edema, tenderness, nodules, taut bands all fall under the objective assessment known as palpation.

A

True

18
Q

TRUE OR FALSE: Muscle spasm is noted even when the pt is at rest.

A

True

19
Q

Tightness or contraction because of pain d/t movement

A

Muscle guarding

20
Q

“Intact deep sensation as to proprioception, kinesthesia & vibration, except” is the heading for what objective assessment?

A

Sensory testing (Deep sensation)

21
Q

“Intact sensation as to light touch, pain, pressure & temperature using cotton, pin, thumb & test tubes as modalities respectively on (B) UE/LE & trunk, except:” is the heading for what objective assessment?

A

Sensory testing (Superficial sensation)

22
Q

“All major joints of (B) UE/LE are WNL, actively & passively done, pain free & c (N) end feel, except” is the heading for what objective assessment?

A

Range of motion measurement

23
Q

“All landmarks are leveled, except:” is the heading for what objective assessment?

A

Postural analysis

24
Q

“All major muscles of (B) UE/LE & trunk graded 5/5, except” is the heading for what objective assessment?

A

Manual muscle testing

25
Q

“Indep in all aspects of ADLs, bed mobility & transfers, except:” is the heading for what objective assessment?

A

Functional Analysis

26
Q

What are the 2 ways of documenting deep tendon reflexes?

A
  1. Writing it down (e.g. O: DTR > Normoreflexive on (B) UE/LE
  2. Using figures
27
Q

TRUE OR FALSE: ++ means brisk response and normoreflexia

A

True

28
Q

TRUE OR FALSE: +++ is for clonus

A

False, it’s ++++

29
Q

Determine the corresponding descriptions of the sections of the SOAP

  1. Includes results of evaluation, diagnosis (PT Impression), and prognosis
  2. Includes patient’s symptoms in which the data are obtained from the patient interview
  3. Factual data gathered from the examination or assessment
  4. Includes signs
  5. Source of information could either be coming from the patient or the caregiver
  6. Conclusion reached about the patient’s problems

A. Subjective
B. Objective
C. Assessment
D. Plan

A
  1. C
  2. A
  3. B
  4. B
  5. A
  6. C
30
Q

A document is considered ___ when it measures what it is supposed to measure.

A

valid

31
Q

A document is considered ___ when it provides the exact same measurement each time. It is the repeatability of the measure.

A

reliable

32
Q

It serves as the foundation of documentation

A

International Classification for Functioning, Disability, and Health (ICF model)

33
Q

Any form of written communication related to patient encounter. It encompasses the preparation and assembly records to authenticate and communicate the care given by a healthcare provider and the reasons for giving that care.

A

Documentation

34
Q

Determine the corresponding objective subheading for the ff findings

  1. NDI, DASH, FIM, WOMAC
  2. Normoreflexive on (B) UE/LE
  3. Elevated (L) shoulder
  4. (R) Anterior Deltoid: Gr. 4/5
  5. Balance and tolerance

A. Ocular inspection
B. Palpation
C. Anthropometric measurement
D. Range of motion
E. Special tests
F. Sensory testing
G. MMT
H. Deep Tendon Reflex
I. Postural Analysis
J. Functional Analysis

A
  1. J
  2. H
  3. I
  4. G
  5. J
35
Q

Determine the corresponding objective subheading for the ff findings

  1. crepitations
  2. 6-minute walk test
  3. (+) Cozen’s test on (R)
  4. chest expansion
  5. (R) ankle eversion: 0 degrees

A. Ocular inspection
B. Palpation
C. Anthropometric measurement
D. Range of motion
E. Special tests
F. Sensory testing
G. MMT
H. Deep Tendon Reflex
I. Postural Analysis
J. Functional Analysis

A
  1. B
  2. J
  3. E
  4. C
  5. D
36
Q

Determine the corresponding classification for the ff findings in Ocular Inspection

  1. (+) hematoma on (R) thigh
  2. (+) bandage on (L) ankle
  3. (+) swelling on ant. aspect of (R) shoulder
  4. Ectomorph
  5. Alert, Conscious, Coherent, Cooperative, and Oriented as to person, place, time

A. Manner of arrival
B. Mental status
C. Body type
D. Attachment
E. Skin integrity
F. Swelling
G. Postural deviations
H. Gait deviations

A
  1. E
  2. D
  3. F
  4. C
  5. B
37
Q

Determine the corresponding descriptions of the manners of arrival

  1. pt is restricted to bed because of medical condition
  2. pt is in w/c when brought to clinic
  3. pt is in stretcher when brought to clinic
  4. pt is restricted to bed because of attachments
  5. pt is bed restricted following MD advice
  6. Amb c quad cane on (R)

A. Bed-ridden
B. Bed-bound
C. Bedfast
D. w/c-borne
E. Ambulatory c assist. device
F. Ambulatory s assist. device
G. Stretcher-borne

A
  1. A
  2. D
  3. G
  4. B
  5. C
  6. E

(2) Musculoskeletal Examination (11 decks)

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