Question 1

2-8-98: Pt. feeling better today. Pt. was seen for a 30 minute therapy visit.
$\quad$S: Mom told PTA that her son is cranky and stiff.
$\quad$O: Worked on sitting and rolling.
$\quad$A: Pt. able to sit by himself for short time periods.
$\quad$P: Continue PT sessions.
-In the SOAP note example provided in Figure , why is the assessment section incorrect?
A) It is correct and no changes are necessary.
B) It needs to include more specific goals for rolling and sitting.
C) It needs to delineate how long the patient sat, compared to the last session.
D) It is correct but should also include the short-term goal of rolling.

Accepted Answer

The assessment section needs to summarize what happened in the objective section. It should provide information based on the skills performed, type of improvement compared to the last session and the relationship of the comparison, and how the skill meets short- or long-term goals set up in the original plan of care.
2-8-98: Pt. feeling better today. Pt. was seen for a 30 minute therapy visit.
S: Mom told PTA that her son is cranky and stiff.
O: Worked on sitting and rolling.
A: Pt. able to sit by himself for short time periods.
P: Continue PT sessions.

Question 2

What specific piece of legislation was responsible for changing the documentation process?
A) Public Law 504
B) The American Disabilities Act
C) The Rehabilitation Act
D) The Health Insurance for the Aged and Disabled Act

Accepted Answer

The Health Insurance for the Aged and Disabled Act, commonly known as Medicare, drove the changes in documentation.

Question 3

Documentation must meet today's standards for reimbursement and provides the basis for research.What two standards must be met for reimbursement to be successful?
A) Measures functional outcomes and identifies effective and efficient treatment
B) Describes functional activities that demonstrate appropriate interventions
C) Identifies appropriate interventions based on the type of treatments
D) Demonstrates effective and efficient treatment

Accepted Answer

Documentation must be effective and efficient, and must measure functional outcomes to meet today's standards for reimbursement.

Question 4

What state became the first state to allow direct access?
A) California
B) Nebraska
C) Maryland
D) New York

Accepted Answer

Nebraska was the first state to allow direct access for physical therapy treatment in 1957.

Question 5

What is the website for the American Physical Therapy Association (APTA)?
A) www.apta.us.net
B) www.apta.org
C) www.apta.com
D) www.apta.us.com

Accepted Answer

The correct website for the APTA is www.apta.org.

Question 6

What is the definition of documentation?
A) Anything written without supplying evidence
B) The use of documentary evidence to support original written work
C) Classifying knowledge that is not readily available
D) The assembling of documents without classification of knowledge

Accepted Answer

Proper documentation must supply evidence, and knowledge must be readily available and classified.

Question 7

When was the first academic program developed for the PTA?
A) 1959
B) 1967
C) 1973
D) 1979

Accepted Answer

The first PTA program was established in 1967.

Question 8

What two events changed treatment and documentation responsibilities for the PT and PTA?
A) Medicare insurance and physician referrals
B) Medicaid insurance and types of documentation
C) HMO and physician referrals
D) Medicare insurance and types of documentation

Accepted Answer

Responsibilities for the PT and PTA changed because of the requirements of Medicare insurance and physician referrals for physical therapy services.

Question 9

2-8-98: Pt. feeling better today. Pt. was seen for a 30 minute therapy visit.
$\quad$S: Mom told PTA that her son is cranky and stiff.
$\quad$O: Worked on sitting and rolling.
$\quad$A: Pt. able to sit by himself for short time periods.
$\quad$P: Continue PT sessions.
-In the SOAP note example provided in Figure , why was the objective section incorrect?
A) It did not report how much assistance was given in sitting and rolling, and could not be followed.
B) It did not report how long the patient was able to sit, but rolling is a skill that can be understood without further clarification.
C) It did not report how many times the patient rolled, but sitting can only be done in one position.
D) It did not report the specific parameters of the treatment session and was not reproducible.

Accepted Answer

The objective section must give information related to the specific time span, amount or type of assistance, and positions or placement of hands for support. It must be easily reproduced by another therapist based on the information given.

Question 10

Which two goals must physical therapy meet for the PT to receive reimbursement for services?
A) Inefficient and disorganized
B) Efficient and organized
C) Effective and efficient
D) Organized and effective

Accepted Answer

Physical therapy must be effective and efficient to ensure appropriate reimbursement for treatment.

Question 11

During which time period did documentation change, requiring more specific information?
A) Mid-1950s
B) Mid-1960s
C) Mid-1970s
D) Mid-1980s

Accepted Answer

The change from general documentation to more specific documentation requirements began in the mid-1960s because of the enactment of Medicare insurance policies.

Question 12

Direct access allows PTs to practice with autonomy because it is understood that PTs recognize their legal responsibilities.What is this legal responsibility called?
A) Scope of practice
B) Legal responsibilities
C) Ethical issues
D) Code of ethics

Accepted Answer

The legal responsibility of the practicing PT relates to the scope of practice for the state in which the PT will practice. Because of this scope of practice, the physical therapist would know when it is legally necessary to refer the patient to a physician or another medical specialist, depending on the symptoms exhibited by the patient.

Question 13

What type of access allows a patient to see a PT without a physician's referral?
A) Indirect
B) Express
C) Timely
D) Direct

Accepted Answer

Direct access provides the ability for a patient to see a PT without a physician's referral.

Question 14

What is the focus of outcomes in patient care related to PT and PTA documentation?
A) The ability to provide cost-effective care for the patient
B) The ability to provide efficient care for the patient
C) The ability to improve functional abilities of the patient
D) The ability to document appropriate patient care

Accepted Answer

It is imperative that treating PTs and PTAs provide a mechanism to improve functional abilities of the patient.

Question 15

What is the name of the accrediting agency for hospitals?
A) CARF
B) CAPTE
C) JCAHO
D) HIPPA

Accepted Answer

The Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, is the accrediting body for hospitals.

Question 16

Why is documentation necessary in patient care?
A) It helps provide written and legal proof that treatment occurred.
B) It does not need to be written if it is reported verbally.
C) It helps determine what one might do with a patient.
D) It is not necessary at all.

Accepted Answer

Information about patient care must be written, not just verbally discussed, or it did not happen. Documentation might help a therapist plan the treatment session, but it is always necessary to provide the written and legal proof of care.

Question 17

Documentation classification has evolved over many years.Which documentation classification provides a definitive summary of an active pathology with the relationship to the resulting impairment?
A) ICIDH Classification
B) National Center for Medical Rehabilitation Research
C) Nagi Disablement Model
D) Functional Impairment Model

Accepted Answer

This is the definition for the Nagi Disablement Model.

Question 18

To provide high-quality medical care, the PT and PTA must demonstrate one exceptional skill.What is that one skill?
A) Writing
B) Organization
C) Treatment
D) Communication

Accepted Answer

The PT and PTA must have exceptional communication skills, both verbally and in writing, to be able to provide high-quality medical care.

Question 19

Which taxonomy can be defined as the loss or abnormality of a physiological, psychological, or anatomical structure or function?
A) Disability
B) Functional Limitation
C) Handicap
D) Impairment

Accepted Answer

This is the definition of impairment.

Question 20

What is the name of the accrediting agency for rehabilitation facilities?
A) CARF
B) CAPTE
C) JCAHO
D) HIPPA

Accepted Answer

The Commission on Accreditation of Rehabilitation Facilities, or CARF, is the accrediting body for rehabilitation facilities.

Quiz 1: Introduction to Documentation

What specific piece of legislation was responsible for changing the documentation process?

Documentation must meet today's standards for reimbursement and provides the basis for research.What two standards must be met for reimbursement to be successful?

What state became the first state to allow direct access?

What is the website for the American Physical Therapy Association (APTA) ?

What is the definition of documentation?

When was the first academic program developed for the PTA?

What two events changed treatment and documentation responsibilities for the PT and PTA?

Which two goals must physical therapy meet for the PT to receive reimbursement for services?

During which time period did documentation change, requiring more specific information?

Direct access allows PTs to practice with autonomy because it is understood that PTs recognize their legal responsibilities.What is this legal responsibility called?

What type of access allows a patient to see a PT without a physician's referral?

What is the focus of outcomes in patient care related to PT and PTA documentation?

What is the name of the accrediting agency for hospitals?

Why is documentation necessary in patient care?

Documentation classification has evolved over many years.Which documentation classification provides a definitive summary of an active pathology with the relationship to the resulting impairment?

To provide high-quality medical care, the PT and PTA must demonstrate one exceptional skill.What is that one skill?

Which taxonomy can be defined as the loss or abnormality of a physiological, psychological, or anatomical structure or function?

What is the name of the accrediting agency for rehabilitation facilities?