Documentation Exam 1

Question 1

Reasons for documentation

Answer 1

communication to other professionals, authentication, litigation, laws, basis for reimbursement

Question 2

Documentation should be…

Answer 2

Precise, concise, legible and timely. with appropriate abbreviation, spelling and corrections if necessary

Question 3

How to sign note

Answer 3

Tyler Courter SPTA and cosigned by PT or PTA

Question 4

Subjective

Answer 4

Patients exact words before, during and after tx. Symptoms/complaints and medical history

Question 5

Objective

Answer 5

What the patient did during the session. Delineate yourself from joe schmo. Tests, measures, data should be reproducible.

Question 6

Assessment

Answer 6

Analysis of S and O. Where PT will document goals. PTA should assess how the patient is responding to tx and whether or not the intervention are effective. Progress compared to past sessions.

Question 7

Plan

Answer 7

What will happen in the next session. What the PTA will do before the next session.

Question 8

Patient Identifiers

Answer 8

Legal Name, DOB, ID, wrist bands

Question 9

Levels of Assist

Answer 9

Independent (Patient does 100%)
Mod I (100% + AD)
Supervision/Stand By (100% + PT/PTA)
Min A (Patient does 75%)
Mod A (50%)
Max A (Patient does 25%)
Total A (Patient does 0%)
Contact Guard (1 or 2 hands on Patient)