Chapter 9, 10: Communication Basics, Documentation, and Medical Records

Question 1

how must the PTs and PTAs communicate?

Answer 1

verbal and nonverbal forms of communication

Question 2

the therapeutic relationship will be highly success if the PT, PTA, and SPTA convey the attitude that they: ?

Answer 2

• value the patient/client
• attentive to the patient/clients needs
• acknowledge the patient/clients message
• genuinely empathize w/ the patient/client
• provide the patient/client w/ the very best care

Question 3

_____ the ability to imagine oneself in another person’s place and to understand the other person’s feelings, ideas, desires, and actions.

Answer 3

empathy

Question 4

what are the 3 stages of HCP and patient/client empathy?

Answer 4

• cognitive stage
• the crossing over stage (most significant)
• the coming back to own feelings stage

Question 5

_____: get into the position of the other persons (listening to pt)

Answer 5

the cognitive stage

Question 6

_____: for a moment the PTA can feel themselves as the patient.

Answer 6

the crossing over stage (most significant)

Question 7

_____: comes back to their own person but feels special alliance w/ the patient.

Answer 7

the coming back to own feelings stage

Question 8

what is the difference of empathy vs. sympathy?

Answer 8

empathy is being able to relate with other through self experiences vs. the ability to understand and support the emotional situation

Question 9

at all times obtain _________ from the patient for the treatment that is about to be rendered.

Answer 9

verbal informed consent

Question 10

______: uses messages conveyed orally from a sender to a receiver.

Answer 10

verbal or oral

Question 11

______: uses messages conveyed through methods other than orally or in writing.

Answer 11

nonverbal

Question 12

what are the deliveries of communication?

Answer 12

• face to face (best method)
• telephone discussions
• group discussions
• third party discussion (through family member or caregiver)

Question 13

what should you know about home exercise program handouts (HEP)?

Answer 13

starts the 1st day of treatment and continues till day of discharge, written at the 5th grade level

Question 14

why do you need to document medical records?

Answer 14

• reimbursement
• assurance quality care
• assurance of continuity of care
• legal reasons
• research and education
• marketing

Question 15

what is the purpose for documentation for reimbursement?

Answer 15

• provides the basis for coverage decisions by third-party payers
• documentation must describe physical therapy effectiveness

Question 16

______:

• consistency w/ APTA’s standards of practice
• must be legible and use medically approved abbreviations or symbols
• must be written in black or blue ink; mistake must be crossed out w/ a single line through the error, initialed, and dated by the PTA

Answer 16

APTA Documentation Guidelines

Question 17

what are the formats for physical therapy documentation?

Answer 17

• POMR
• SOAP
• SOMR

Question 18

POMR?

Answer 18

problem-oriented medical record

- sections include data, problem list, treatment plan, progress notes, discharge notes

Question 19

SOAP?

Answer 19

Subjective, Objective, Assessment, Plan

Question 20

SOMR?

Answer 20

source-oriented medical record

- many hospital charts use SOMR, w/ different sections for physicians, nurses, physical therapy, lab, etc.

Question 21

What does the SOAP format stand for?

Answer 21

subjective - information provided by the patient
objective - results of tests, measurements, and interventions
assessment - overall response to interventions and the effects of interventions, changes in patient status, and the HCP’s opinion about the patients progress
plan - plan for further diagnostic or therapeutic action or for the next treatment section.

Question 22

what are the types of physical therapy documentation reports?

Answer 22

• initial evualtion reports (PT)
• daily / weekly notes (PT/PTA)
• progress reports (PT)
• discharge reports/summaries (PT)

Question 23

______: foundational document for all other reports that follow, through the evaluation the PT establishes the primary purpose for intervention and outlines the expectation for progress

Answer 23

initial evaluation reports

Question 24

An initial evaluation report may include?

Answer 24

• referral prescription
• physical therapy history
• referral diagnosis
• prior therapy history

Question 25

______ includes diagnosis, onset date, complications or precautions, frequency/duration

Answer 25

referral / prescription

Question 26

_____ includes DOB, age, gender, SOC, primary compliant

Answer 26

physical therapy history

Question 27

_____ includes mechanism of injury; prior diagnostic imaging or testing.

Answer 27

referral diagnosis

Question 28

what do PTAs write?

Answer 28

daily/weekly treatment notes

Question 29

what do PTs write?

Answer 29

evaluations, progress reports, and discharge reports

Question 30

what is evidence-based care/practice?

Answer 30

“entails making decisions about how to promotes health or provide care by integrating the best available evidence w/ practitioner expertise and other resources.”

Question 31

evidence-based practice needs?

Answer 31

to be documented using researched clinical guidelines and approved PT protocols.

Question 32

what are the types of computerized documents for medical records?

Answer 32

• electronic medical records (EMR)

- electronic health records (EMR)

Question 33

what are the benefits of electronic medical documentation?

Answer 33

• submitting info to insurance companies electronically
• monitoring clinician’s productivity
• tracking patients’ visits
• minimizing documentation paperwork
• integrating billing

Question 34

the physical therapist (PT) establishes the primary purpose for intervention and outlines the expectations for progress in which type of physical therapy documentation report?

Answer 34

initial evaluation report