Documentation, Ethics & Standards Flashcards
What does SOAP stand for in SOAP documentation?
S = Subjective data, O = Objective data, A = Assessment, P = Plan
What type of data is documented under ‘S’ in SOAP documentation?
Subjective data
Includes patient experiences, feelings, duration, intensity, and past history.
What is included in the ‘O’ section of SOAP documentation?
Objective data
Includes interventions, physical exam results, and vital signs.
What is assessed in the ‘A’ section of SOAP documentation?
Assessment
Includes diagnosis, problem identification, and treatment tolerance.
What is documented in the ‘P’ section of SOAP documentation?
Plan
Includes follow-up, further testing, and treatment goals.
What does DAR stand for in DAR documentation?
D = Data, A = Action, R = Response
What is included in the ‘D’ section of DAR documentation?
Data
Comprised of subjective and objective information related to a problem.
What types of data can be included as subjective data in DAR documentation?
Examples include direct patient quotes like ‘I can’t breathe’ or ‘I’m scared’
What does the ‘A’ in DAR documentation refer to?
Action
Refers to past, present, or future actions based on patient assessment.
What is described in the ‘R’ section of DAR documentation?
Response
Describes patient progress and response to therapy.
What is the primary role of physiotherapists as experts?
To promote, improve, and maintain mobility, health, and well-being
What does the physiotherapist role of ‘Communicator’ involve?
Using effective communication to develop professional relationships
What is the responsibility of physiotherapists as ‘Managers’?
To manage time, resources, and priorities for sustainable practice
What is required for the maintenance of clinical records?
An accurate, legible, permanent, and confidential record must be maintained
What must be included in a clinical record regarding patient consent?
All consents given by a patient or their legal representative
What must be documented regarding changes in patient status?
Any change in patient status and/or treatment provided must be documented
What is the minimum retention period for clinical records?
16 years from the date of the last entry
How must clinical records be destroyed to maintain confidentiality?
By effective shredding, burning, or computer/video erasure
What is the definition of electrophysical agents?
Electrical, electromagnetic, thermal, light, or sound energies used therapeutically
What must all electrophysical agents have according to regulations?
A medical device license issued by Health Canada
What is required before using new electrophysical equipment?
Calibration must be performed according to manufacturers’ specifications
What must be verified before applying an electrophysical agent?
There must be no contraindications to the proposed application
What must be documented after applying an electrophysical agent?
Modality, dosage, specific area treated, and response to treatment
What is the role of a PT support worker?
To assist in the provision of physiotherapy services under a physiotherapist’s direction
What must a physiotherapist ensure about the PT support worker?
That the support worker is competent to replicate the correct application procedure
What should be documented regarding treatment plans?
Proposed treatment plan and any changes made to it must be documented
What is the role of the PTA?
To assist the physiotherapist in ensuring that physiotherapy services are delivered in a safe, effective, and efficient manner.
PTAs help provide physiotherapy services that achieve and maintain optimal client outcomes.
How does the relationship between the physiotherapist and the PTA vary?
It is dynamic, with the type of supervision and tasks assigned determined by the supervising physiotherapist in accordance with provincial physiotherapy regulations.
What factors do physiotherapists consider when assigning tasks to PTAs?
Education, training, competence of PTAs, complexity and stability of individual client needs, and the environment.
Are PTAs accountable for their own performance?
Yes, PTAs are accountable for their own individual performance.
What does ‘assignment of task’ mean?
Transfer of a component of a physical therapy treatment plan to a physical therapist support worker.
What is a Physical Therapist Support Worker (PTSW)?
An individual who works under the direction and supervision of a physical therapist.
What is the definition of supervision in the context of PTSWs?
The means by which the physical therapist monitors the performance of the PTSW to ensure competent care.
What are the two types of supervision?
- Direct supervision (physical therapist is present)
- Indirect supervision (physical therapist is not present)
What accountability do physical therapists have regarding task assignment?
Physical therapists must demonstrate accountability for the assigning process, including monitoring and supervision of the PTSW.
What is the first step in assigning a task?
Explaining to each patient the relationship between the physical therapist and the PTSW.
What must be obtained from each patient regarding the involvement of a PTSW?
Informed consent.
What should a physical therapist do if a patient revokes consent?
The PTSW must be made aware that patient consent can be revoked at any time.
What is required before a PTSW can carry out assigned tasks?
The PTSW must be taught the assigned task and deemed competent.
What should a PTSW do in case of adverse treatment reactions?
Cease treatment and immediately report to the appropriate person as indicated in the supervision plan.
What must be documented in the supervision and communication plan?
An appropriate supervision and communication plan must be established and documented.
What must physical therapists do in the event of planned or unplanned absences?
Have an appropriate supervision and communication plan in place or arrange for transfer of supervision to another physical therapist.
What tasks are appropriate for PTAs?
- Fit/adjust an assistive/ambulation device
- Supervision of exercise activities
- Gait training activities
- Daily progress notes
- Apply modalities (without determining prescription)
What tasks must NOT be assigned to PTSWs?
- Interpretation of referrals, diagnosis, or prognosis
- Performance of assessment/evaluative procedures
- Interpretation of assessment findings
- Discussion of physical therapy diagnosis or treatment rationale
- Planning or initiating physical therapy treatment goals or programs
- Tasks requiring a physical therapist’s clinical judgment
- Modification of treatment beyond established limits
- Completion of documentation that is the physical therapist’s responsibility
- Teaching of the assigned task to another person
- Discharge planning
What is necessary for documenting assigned tasks?
Documentation must include details of the assigned tasks, identity of the support worker, supervision plan and process, and any changes made.
What must physical therapists ensure regarding receipts when billing on a fee-for-service basis?
Receipts must be transparent and indicate who is providing physical therapy treatment on a given day.
True or False: A physical therapist can submit inaccurate billing accounts.
False
What is the responsibility of each physical therapist regarding consent?
To read and be familiar with the consent requirements as set out in the Health Care Consent and Facilities Admission Act (HCCFAA) and the Infant’s Act.
What are the methods by which a physical therapist may obtain consent?
Consent may be expressed orally, in writing, or implied from the client’s words, writing, and/or actions.
What must a written consent form include?
- Patient’s name and signature
- Date
- Brief description of the treatment or procedure
- Name of the physical therapist
- Any other relevant information
What is required for valid patient consent?
Clear and ongoing communication between the physical therapist and the patient.
What must be documented in the clinical record regarding consent?
Documentation that informed consent has occurred and a client’s refusal to consent, including explanations of the consequences.
What information must a physical therapist provide to the patient for informed consent?
- Nature, purpose, and risks of treatment
- Alternative treatments
- Consequences of refusing treatment
What is the definition of informed consent?
Consent is informed if the person received information that a reasonable person would require to make a decision about treatment.
True or False: Consent to health care applies only to the specific health care consented to.
True.
What are the rights of every adult regarding consent to health care?
- Right to give or refuse consent on any grounds
- Right to select a form of health care
- Right to revoke consent
- Right to expect decisions will be respected
- Right to be involved in case planning
What constitutes an adult’s consent to health care?
- Relates to proposed health care
- Given voluntarily
- Not obtained by fraud or misrepresentation
- Adult is capable of making a decision
- Provider gives necessary information
- Opportunity to ask questions
Who can provide substitute consent for an adult?
- Adult’s spouse
- Adult’s child
- Adult’s parent
- Adult’s sibling
- Adult’s grandparent
- Adult’s grandchild
- Anyone related by birth or adoption
- Close friend
- Person related by marriage
What criteria must a person meet to qualify for giving substitute consent?
- At least 19 years old
- Contact with adult in the last 12 months
- No dispute with adult
- Capable of giving consent
- Willing to comply with adult’s wishes
What must a physical therapist do if a treatment plan is altered?
Update patient consent.
What does the term ‘mature minor’ refer to in consent?
An infant may consent if they understand the nature and consequences of health care and it is in their best interests.
According to College Bylaws, what is forbidden in the relationship between a physical therapist and a patient?
A sexual relationship.
What are the signs of boundary crossing in a therapeutic relationship?
- Excessive time spent with a patient
- Choosing patients based on looks or social standing
- Sharing personal problems
- Providing personal contact information
What is a conflict of interest in the context of physical therapy?
A breach of professional ethics advancing one’s own or another’s interests to the detriment of the client.
What are the characteristics of a professional relationship compared to a personal relationship?
- Professional: Limited duration, confined location, purpose to provide care
- Personal: May last a lifetime, no boundaries, for enjoyment
What should a physical therapist do regarding draping for patients?
- Equip practice with clean draping materials
- Explain purpose of undressing
- Maintain patient dignity
- Drape according to patient needs
What title should a physical therapist not use when providing patient care services?
Doctor or an abbreviation of the title (Dr).
What must be communicated clearly, consistently, and completely?
Information about additional education, preferred areas of practice, or practice area of interest.
How should physical therapists communicate practice limitations?
Practice limited to hand therapy or PT with additional education in pediatric therapy.
Are professional association memberships considered credentials?
No, they must not be conveyed as such.
What is an example of a professional association membership?
MCPA (member of the Canadian Physiotherapy Association).
What title must physical therapists with a doctorate degree avoid using when providing patient care?
Doctor or an abbreviation of the title (Dr).
How should the doctoral degree be noted after a physical therapist’s name?
With related physical therapist qualification, e.g., BHSc(PT), PhD.
What must physical therapists who practice multiple disciplines do regarding their roles?
Keep their roles, titles, credentials, documentation, and billing practice separate and distinct.
Fill in the blank: Physical therapists who hold a doctorate degree must not use the title ‘_______’ when providing patient care services.
doctor
True or False: Physical therapists can present their professional association memberships as credentials.
False
What is the purpose of the Canadian Physiotherapy Code of Ethics?
To frame the core values of the physiotherapy profession in Canada and provide guidelines for professional behaviour.
What are the three main responsibilities outlined in the Canadian Physiotherapy Code of Ethics?
- Responsibilities to the patient/client
- Responsibilities to society
- Responsibilities to the profession
What does ‘respect and dignity’ mean in the context of the Code of Ethics?
To acknowledge, value and appreciate the worth of all patients/clients.
What principle refers to respecting a patient/client’s right to make decisions?
Respect for patient/client autonomy.
What is the principle of beneficence?
To provide benefit to patients/clients.
What does non-maleficence mean?
To do no harm to patients/clients.
What is meant by responsibility in the Code of Ethics?
To be reliable and dependable.
Define trustworthiness and integrity in the context of the Code of Ethics.
To be honest and to be trusted.
What is the expectation of professionalism in the Code of Ethics?
To be a good citizen/member in good standing of the professional association.
True or False: CPA members can refuse care to any patient/client based on their social status.
False.
What is a key responsibility of CPA members towards their patients/clients?
To promote the health and well-being of patients/clients while respecting their rights.
What must CPA members respect regarding patients’ rights?
- Rights to be informed about treatment effects
- Rights to consent to or decline treatment
- Rights to privacy and confidentiality
Fill in the blank: CPA members must practice in a _______ manner within their individual scope of practice.
[safe, competent, accountable and responsible]
What is the responsibility of CPA members towards society?
To improve the standards of health care and the well-being of society.
What must CPA members comply with in their practice?
All legislation and regulatory requirements pertaining to physiotherapy.
What is one responsibility of CPA members to their profession?
To uphold the integrity of the profession.
What does it mean for CPA members to strive for excellence?
To commit to maintaining and enhancing the reputation and standing of the physiotherapy profession.
What is expected regarding the sharing of best practices among CPA members?
To share evidence-informed and clinical best practices with each other and other health care professionals.
What role do CPA members have concerning students?
To be willing and diligent preceptors of students.
Fill in the blank: The _____ scale is commonly used to measure pain intensity in patients.
Visual Analog
What is the purpose of using outcome measures in physiotherapy?
To evaluate patient progress and treatment effectiveness.
Which outcome measure assesses functional ability in patients with lower extremity injuries?
The Lower Extremity Functional Scale (LEFS)
Multiple Choice: Which of the following is NOT a common MSK outcome measure? A) Oswestry Disability Index B) Berg Balance Scale C) Mini Mental State Examination
C) Mini Mental State Examination
What type of outcome measure is the Numeric Pain Rating Scale?
A unidimensional measure of pain intensity
True or False: Patient-reported outcome measures (PROMs) only focus on physical health.
False
What does the Oswestry Disability Index assess?
The degree of disability in patients with low back pain.
Short Answer: Name one psychometric property that is important for outcome measures.
Reliability
Multiple Choice: Which outcome measure is specifically designed for knee osteoarthritis? A) Western Ontario and McMaster Universities Osteoarthritis Index B) Knee Injury and Osteoarthritis Outcome Score C) Both A and B
C) Both A and B
True or False: The 6-Minute Walk Test is used to measure cardiovascular endurance.
True
What is the main focus of the Patient-Specific Functional Scale?
To evaluate the patient’s perceived functional limitations related to their condition.
Fill in the blank: The _____ is a common measure used to assess balance and fall risk.
Berg Balance Scale
Fill in the blank: The __________ scale is commonly used to assess the severity of motor impairment in patients with stroke.
Fugl-Meyer Assessment
Which outcome measure is specifically designed for assessing balance in patients with neurological disorders?
Berg Balance Scale
Multiple Choice: Which of the following is NOT a common neurological outcome measure? A) Barthel Index B) Mini-Mental State Examination C) Visual Analog Scale
C) Visual Analog Scale
What aspect of patient performance does the Ashworth Scale measure?
Muscle tone and spasticity
True or False: The 6-Minute Walk Test is used to assess endurance in patients with neurological impairments.
True
Short Answer: Name one outcome measure that evaluates cognitive function in neurological patients.
Montreal Cognitive Assessment (MoCA)
Fill in the blank: The __________ is used to measure the quality of life in patients with neurological conditions.
Neurological Quality of Life Scale
Multiple Choice: Which outcome measure is used to assess gait speed? A) Functional Reach Test B) 10-Meter Walk Test C) Gait Abnormality Rating Scale
B) 10-Meter Walk Test
What does the term ‘validity’ refer to in the context of outcome measures?
The extent to which an outcome measure accurately assesses what it intends to measure.
True or False: Reliability refers to the consistency of a measurement over time.
True
Fill in the blank: The __________ scale is often used to assess pain in patients with neurological disorders.
Numeric Pain Rating Scale
Short Answer: What is the role of the Functional Independence Measure (FIM)?
To assess the level of a patient’s disability and the amount of assistance required for daily living activities.
Multiple Choice: Which of the following measures is commonly used to assess upper limb function? A) Jebsen-Taylor Hand Function Test B) Katz Index C) Tinetti Test
A) Jebsen-Taylor Hand Function Test
What is the main focus of the Rivermead Mobility Index?
To evaluate mobility and functional recovery in stroke patients.
True or False: The Dynamic Gait Index assesses a patient’s capacity to modify gait in response to changing task demands.
True
Fill in the blank: The __________ is a scale used to assess the severity of cognitive impairment in patients with dementia.
Clinical Dementia Rating Scale
Short Answer: Why is it important to use standardized outcome measures in physiotherapy?
To ensure consistency, reliability, and comparability of results across different settings and populations.
What is the primary purpose of the Chedoke-McMaster Stroke Assessment?
To assess and quantify the level of motor recovery in stroke patients.
True or False: The Chedoke-McMaster Stroke Assessment includes both upper and lower limb assessments.
True
Fill in the blank: The Chedoke-McMaster Stroke Assessment is designed to measure __________ in patients post-stroke.
functional abilities
What are the two main components of the Chedoke-McMaster Stroke Assessment?
The impairment inventory and the activity inventory.
Multiple Choice: Which of the following does NOT form part of the Chedoke-McMaster Stroke Assessment? A) Upper limb function B) Cognitive assessment C) Lower limb function D) Balance assessment
B) Cognitive assessment
What does AIMS stand for?
Alberta Infant Motor Scale
True or False: AIMS is used to assess the motor development of infants.
True
Fill in the blank: The AIMS is primarily designed for infants aged _____ months.
0 to 18
Which of the following is NOT a category assessed by the AIMS? A) Prone B) Supine C) Walking D) Sitting
C) Walking
Short Answer: What is the main purpose of the Alberta Infant Motor Scale?
To evaluate the motor development of infants and identify potential developmental delays.
