Question 1

The majority of content organization models use a specific approach to arrange information.Identify the correct method most commonly used in documentation.
A) Systems approach
B) Disease process approach
C) Problem-solving approach
D) Time process approach

Accepted Answer

Content organization models most commonly use a problem-solving approach by gathering and interpreting results, setting goals, and adapting treatment to meet those goals.

Question 2

Identify the term that is defined by the "inability to engage in age-specific, gender-specific or sex-specific roles in a particular social context and physical environment."
A) Impairment
B) Functional limitation
C) Disability
D) Handicap

Accepted Answer

Disability is defined as the "inability to engage in age-specific, gender-specific or sex-specific roles in a particular social context and physical environment."

Question 3

Prior to receiving treatment from a PT, the patient is given information regarding the treatment process and the right to refuse treatment.This information process is known as:
A) informed consent.
B) an incident report.
C) a confidentiality consent.
D) permission to treat.

Accepted Answer

The process of giving the patient information regarding the treatment procedure and allowing the patient the right to accept or refuse the treatment session is known as informed consent.

Question 4

Of the four types of documentation included in Chapter 4, which one does NOT include "plan" in their content?
A) SOAP
B) PSP
C) PSPG
D) DEP

Accepted Answer

DEP includes data, evaluation, and performance, not plan.

Question 5

Different formats are often used in documentation.One type uses computerized documentation.However, this type of documentation can be problematic for the PTA.Why would this type of documentation cause a problem?
A) It is very complicated to use and does not provide specific parameters related to patient care.
B) It is simple to use and provides the PTA with a concise checklist for the treatment given.
C) It provides an organized checklist for treatment but is not patient specific.
D) It provides a concise checklist for treatment but does not give specific parameters related to patient care.

Accepted Answer

Computerized documentation provides preprogrammed statements to quickly compose content in a note. However, this type of documentation does not always provide the reasons for the necessity of skilled intervention.

Question 6

Which type of medical record organization uses an outline type format to document what happens during the patient treatment session?
A) POMR
B) SOAP
C) FOR
D) SOMR

Accepted Answer

Formats using SOAP, or subjective, objective, assessment, and plan, are organized around an outline of the activities that occur during a treatment session, and are more widely used than any other type of format.

Question 7

In what type of setting would you use an IEP?
A) A hospital
B) An inpatient rehabilitation facility
C) An outpatient clinic
D) A school

Accepted Answer

An IEP is an individualized educational plan and is used in the school setting.

Question 8

Identification of pathokinesiological problems associated with faulty biomechanical or neuromuscular action is the definition of which of the following terms?
A) Functional limitation
B) Medical diagnosis
C) Physical therapy diagnosis
D) Disability

Accepted Answer

Identification of pathokinesiological problems associated with faulty biomechanical or neuromuscular action is the definition of a physical therapy diagnosis, whereas a medical diagnosis is a systemic disease or disorder that is determined by a physician's evaluation and diagnostic tests.

Question 9

Medical records are often organized following specific formats.Which type of format is organized around the identification and treatment of the patient's problems?
A) POMR
B) SOAP
C) FOR
D) SOMR

Accepted Answer

Formats using POMR, or problem-oriented medical records, are organized around the identification and treatment of the patient's problem.

Question 10

Which type of format is organized around the medical services offered in the clinical facility?
A) POMR
B) SOAP
C) FOR
D) SOMR

Accepted Answer

Formats using SOMR, or source-oriented medical records, are organized around the types of medical services offered in the clinical facility.

Question 11

Documentation content can be grouped into six categories.Identify one of the correct categories.
A) Information related to the patient's problem requiring medical treatment
B) Information related to the patient's ability to pay for treatment
C) Information related to the patient's living conditions
D) Information related to the patient's ability to speak English

Accepted Answer

Documentation content includes data relevant to the patient's condition, the problem requiring medical treatment, the treatment plan, goals or outcomes, record of the administration of the treatment plan, and treatment effectiveness or results of the treatment plan.

Question 12

Which type of format is organized so that the various disciplines have the ability to review the problem and treatment necessary for the patient from ONE place in the medical record?
A) POMR
B) SOAP
C) FOR
D) SOMR

Accepted Answer

Formats using POMR, or problem-oriented medical records, provide enhanced communication among disciplines because the problem identified and being treated is included in one place.

Question 13

Identify the term that is defined as the "abnormalities or dysfunctions of the bones, joints, ligaments, muscles, tendons, nerves, and skin, or problems with movement resulting from an injury to or abnormality of the brain, spinal cord, pulmonary, or cardiovascular systems."
A) Impairment
B) Functional limitation
C) Disability
D) Handicap

Accepted Answer

Impairment is defined as "abnormalities or dysfunctions of the bones, joints, ligaments, muscles, tendons, nerves, and skin, or problems with movement resulting from an injury to or abnormality of the brain, spinal cord, pulmonary, or cardiovascular systems."

Question 14

Under what circumstances might a PT or PTA use a letter format when providing documentation about a treatment session?
A) When providing information to the occupational therapist regarding the patient's goals
B) When providing information to a physician regarding the patient's progress
C) When providing information to a nurse regarding the patient's vital signs
D) When providing information to the speech therapist regarding the patient's posture

Accepted Answer

This type of format is commonly used when providing a summary on the patient's condition and progress to the patient's physician.

Question 15

Which type of format is often criticized because it takes too much time to read through each section for information?
A) POMR
B) SOAP
C) FOR
D) SOMR

Accepted Answer

Formats using SOMR, or source-oriented medical records, are often criticized because it takes too long to read through each section for information, making it difficult to audit for reimbursement and quality control.

Question 16

Which documentation method includes a plan section as part of the note?
A) PCP
B) DEP
C) SOAP
D) HIPPA

Accepted Answer

The SOAP format is one method of documentation that includes a plan section (S-subjective, O-objective, A-assessment, and P-plan).

Question 17

There are multiple methods used to document care given to patients related to physical therapy treatment.What method uses a problem, status, and plan review?
A) SOAP notes
B) PSP notes
C) PSPG notes
D) DEP notes

Accepted Answer

The PSP uses a problem, status, and plan approach.

Question 18

Which type of medical record format uses a structured approach for reporting function and outcome?
A) POMR
B) SOAP
C) FOR
D) SOMR

Accepted Answer

Formats using FOR, or functional outcome reporting, are organized around the functional assessment and outcomes related to patient care.

Question 19

What discipline is responsible for providing the therapy evaluation of the patient prior to the treatment session?
A) Physician
B) PTA
C) PT
D) Social worker

Accepted Answer

The PT is the discipline responsible for completing the evaluation of the patient for appropriate therapeutic intervention prior to treatment.

Question 20

Identify the term that is defined as "a restriction of the ability to perform."
A) Impairment
B) Functional limitation
C) Disability
D) Handicap

Accepted Answer

Functional limitation is defined as "a restriction of the ability to perform."

Quiz 4: Documentation Content and Organization

The majority of content organization models use a specific approach to arrange information.Identify the correct method most commonly used in documentation.

Identify the term that is defined by the "inability to engage in age-specific, gender-specific or sex-specific roles in a particular social context and physical environment."

Prior to receiving treatment from a PT, the patient is given information regarding the treatment process and the right to refuse treatment.This information process is known as:

Of the four types of documentation included in Chapter 4, which one does NOT include "plan" in their content?

Different formats are often used in documentation.One type uses computerized documentation.However, this type of documentation can be problematic for the PTA.Why would this type of documentation cause a problem?

Which type of medical record organization uses an outline type format to document what happens during the patient treatment session?

In what type of setting would you use an IEP?

Identification of pathokinesiological problems associated with faulty biomechanical or neuromuscular action is the definition of which of the following terms?

Medical records are often organized following specific formats.Which type of format is organized around the identification and treatment of the patient's problems?

Which type of format is organized around the medical services offered in the clinical facility?

Documentation content can be grouped into six categories.Identify one of the correct categories.

Which type of format is organized so that the various disciplines have the ability to review the problem and treatment necessary for the patient from ONE place in the medical record?

Identify the term that is defined as the "abnormalities or dysfunctions of the bones, joints, ligaments, muscles, tendons, nerves, and skin, or problems with movement resulting from an injury to or abnormality of the brain, spinal cord, pulmonary, or cardiovascular systems."

Under what circumstances might a PT or PTA use a letter format when providing documentation about a treatment session?

Which type of format is often criticized because it takes too much time to read through each section for information?

Which documentation method includes a plan section as part of the note?

There are multiple methods used to document care given to patients related to physical therapy treatment.What method uses a problem, status, and plan review?

Which type of medical record format uses a structured approach for reporting function and outcome?

What discipline is responsible for providing the therapy evaluation of the patient prior to the treatment session?

Identify the term that is defined as "a restriction of the ability to perform."