Question 1

According to the APTA's Guide to Physical Therapist Practice, there are five elements of physical therapy patient management.What is the first step that should be completed in this process?&#10;A)Examination&#10;B)Evaluation&#10;C)Diagnosis&#10;D)Intervention

Accepted Answer

The first step in the physical therapy patient management process is examination, which involves gathering history and performing tests and measures to identify potential impairments, functional limitations, and disabilities. Evaluation (B) is the second step, which involves making judgments about the data collected during examination to identify problems that can be addressed by physical therapy. Diagnosis (C) is the third step, which involves labeling the patient's condition based on examination and evaluation findings. Intervention (D) is the fourth step, which involves implementing and modifying a plan of care to address the patient's identified problems. The final step is outcome assessment, which involves determining the effectiveness of the plan of care and reexamining the patient to determine if additional intervention is necessary.

Question 2

Evaluating the ability of the patient to move in a smooth, coordinated manner as he or she transitions in and out of a position is known as evaluating:&#10;A)cognitive abilities.&#10;B)normal reflex patterns.&#10;C)motor planning.&#10;D)quality of movement.

Accepted Answer

Evaluating the ability of the patient to move in a smooth, coordinated manner as he or she transitions in and out of a position is an assessment of the quality of movement. Option A, cognitive abilities, is not relevant to this type of evaluation. Option B, normal reflex patterns, may be assessed in some cases but is not specific to evaluating smooth, coordinated movement. Option C, motor planning, is related to the ability to plan and execute movement but does not specifically address the quality of movement during transitions.

Question 3

Why is it important to document reasons for skilled therapeutic intervention in the initial evaluation?&#10;A)To help the patient learn what activities are important for his or her return to work&#10;B)To provide the caregiver or family with a home exercise program&#10;C)To provide evidence to third-party payers that PT services are necessary&#10;D)To prove to the treating facility that PT services are needed

Accepted Answer

Documenting the reasons for skilled therapeutic intervention in the initial evaluation is necessary to provide evidence to third-party payers that PT services are necessary. This is important to ensure that the patient receives the appropriate, necessary care and to avoid denial of reimbursement for services. While options A and B may be important considerations in the therapeutic process, they are not directly related to the initial documentation of reasons for intervention. Option D is incorrect as the purpose of documentation is not to prove PT services are needed to the treating facility but rather to third-party payers.

Question 4

Choose the item that would not be included in the section of the initial examination process that reviews the patient's history.&#10;A)Social history&#10;B)Medications&#10;C)Goals and outcomes&#10;D)Functional status

Accepted Answer

Reviewing goals and outcomes would typically be part of the plan of care and not part of the initial examination process that reviews the patient's history. The other options (social history, medications, and functional status) are common components of the patient's history that are typically reviewed during the initial examination process.

Question 5

In which portion of the PT note would completion of the therapeutic goals be included?&#10;A)Subjective data&#10;B)Summation of care&#10;C)Plan of care&#10;D)Initial evaluation

Accepted Answer

The summation of care includes the overall progress of the patient's treatment, including the completion of therapeutic goals. The subjective data refers to the patient's symptoms and feelings, the plan of care outlines what needs to be done to achieve the goals, and the initial evaluation provides a baseline assessment of the patient's condition at the start of treatment.

Question 6

What information would be included in the subjective section of the SOAP note when the PT completes the initial evaluation?&#10;A)Referral to another medical practitioner&#10;B)Active range of motion (AROM) parameters&#10;C)The patient's progress&#10;D)Pain level prior to treatment

Accepted Answer

The subjective section of the SOAP note during the initial evaluation would include the patient's pain level prior to treatment. This information helps the PT understand the severity of the patient's symptoms and helps guide the treatment plan. Information regarding referral to another medical practitioner, AROM parameters, and the patient's progress would be included in later SOAP notes as the patient continues with treatment.

Question 7

Documentation responsibilities are shared by the PT and the PTA.Identify the responsibility that the PTA may complete within his or her scope of practice.&#10;A)Discharge summary&#10;B)Initial evaluation&#10;C)Progress note&#10;D)Changes to plan of care

Accepted Answer

The PTA may complete progress notes within his or her scope of practice, documenting the patient's ongoing progress and response to treatment. The other options (A, B, D) are typically completed by the PT, as they involve higher levels of clinical decision-making and evaluation.

Question 8

When the patient is ready for the discharge process, who is responsible for discharge from physical therapy services?&#10;A)Primary care physician&#10;B)Nursing supervisor&#10;C)PT&#10;D)PTA

Accepted Answer

The physical therapist (PT) is responsible for discharge from physical therapy services as they are the ones who have been working with the patient directly and are most familiar with their progress and goals. The primary care physician may be consulted for medical clearance, but the PT ultimately determines when the patient is ready to discharge from PT services. Nursing supervisors and PTAs may be involved in assisting with the discharge process, but the ultimate responsibility lies with the PT.

Question 9

The PT has asked the PTA to perform an initial evaluation on a patient, stating, "You have watched me do evaluations for over 2 years now and I think you are ready to do this one.I will watch you, make changes to it, and sign it when you are finished." What would be the appropriate course of action for the PTA?

A)Tell the PT that the evaluation is not within the PTA's scope of practice and refuse to complete it.
B)Tell the PT that, as a PTA, he or she only feels comfortable doing the objective section of the evaluation.
C)Complete the evaluation and have the PT review it and sign it.
D)Report the PT to his or her supervisor.

Accepted Answer

PTAs are not licensed to perform initial evaluations; it is outside their scope of practice.

Question 10

What helps determine the type of documentation used when treating a patient?&#10;A)Patient's diagnosis&#10;B)Type of setting&#10;C)The plan of care&#10;D)The third-party payer

Accepted Answer

The type of setting will dictate the information that needs to be included in the documentation related to patient care.

Question 11

How can a PT or PTA determine a patient's cognitive level?&#10;A)By asking questions related to person, place, and thing&#10;B)By asking questions related to the weather, time of day, and the person's gender&#10;C)By asking questions about the person's prior level of function&#10;D)By asking questions about the person's name, occupation, and educational level

Accepted Answer

The answer of How can a PT or PTA determine...

Question 12

The ability of patients to catch themselves if they lose their balance or their center of gravity shifts too far in one direction is defined as:&#10;A)abnormal reflex patterns.&#10;B)automatic reactions.&#10;C)autonomic reactions.&#10;D)abnormal postural changes.

Accepted Answer

The answer of The ability of patients to catch themselves...

Question 13

Within the component section of the evaluation, the PT looks at the patient's tone.How does tone affect the outcome of the evaluation?&#10;A)Changes in tone can make the patient fatigue much more quickly.&#10;B)Changes in tone can affect the patient's functional abilities.&#10;C)Changes in tone can affect the patient's ability to think.&#10;D)Changes in tone do not affect the patient's ability to walk.

Accepted Answer

The answer of Within the component section of the evaluation,...

Question 14

When the PT performs the evaluation of the patient, what would be the most important factor to consider related to the evaluation process?&#10;A)Functional abilities&#10;B)Cognitive abilities&#10;C)Communication abilities&#10;D)Quality of movement

Accepted Answer

The answer of When the PT performs the evaluation of...

Question 15

Why is it important to know the patient's pain level prior to the treatment session?&#10;A)To determine whether the patient needs pain medication&#10;B)To determine whether the patient cannot perform the exercises that day&#10;C)To determine whether the patient has increased or decreased pain following the treatment session&#10;D)It has no bearing on the treatment session.

Accepted Answer

The answer of Why is it important to know the...

Question 16

What does the diagnosis help the PT determine during the evaluation process?&#10;A)Ability of the patient to progress through the plan of care&#10;B)Amount of support that will be provided by the patient's family&#10;C)Impact on the patient's ability to learn and communicate&#10;D)Impairments and functional limitations of the patient

Accepted Answer

The answer of What does the diagnosis help the PT...

Question 17

It is important to use appropriate terminology when referring to the patient in the documentation process.This process is known as "person-first terminology." Identify the correct statement that meets the requirements of person-first terminology.

A)The paralyzed patient, Mr.Jones, was able to walk 20 feet today.
B)The CVA patient was doing better today.
C)Mrs.Smith, who has a left transtibial amputation, is getting her prosthesis today.
D)The TBI male in room 603 was combative today and needed to be moved.

Accepted Answer

The answer of It is important to use appropriate terminology...

Question 18

The patient's medical record includes, but is not limited to, 11 sections.Choose the section that is usually not included in the medical record.&#10;A)History&#10;B)Plan of care&#10;C)Tests and measures&#10;D)Parent's occupation

Accepted Answer

The answer of The patient's medical record includes, but is...

Question 19

The anticipated discharge plans would be part of what section within the initial evaluation completed by the PT?&#10;A)Plan of care&#10;B)Prognosis&#10;C)Tests and measures&#10;D)Systems review

Accepted Answer

The answer of The anticipated discharge plans would be part...

Question 20

A judgment about the level of optimal improvement the patient may attain and the amount of time needed to reach that level is the definition of:&#10;A)evaluation.&#10;B)intervention.&#10;C)examination.&#10;D)prognosis.

Accepted Answer

The answer of A judgment about the level of optimal...

Deck 6: Physical Therapy Patient Management and Documentation Responsibilities