Exam 1 Key Terms & Review Questions

Question 1

Active pathology

Answer 1

part of Nagi model; interruption of normal body function at the cellular level

Question 2

Americans with Disabilities Act of 1990 (ADA)

Answer 2

Public Law 101–336, that contains five titles and provides “a clear and comprehensive national mandate for the elimination of dis-crimination against individuals with disabilities”

Question 3

Disability

Answer 3

part of Nagi model; functional limitations that pre-vent an individual from fulfilling his/her life roles

Question 4

Education for All Handicapped Children Act of 1975 (EHA)

Answer 4

focuses on ensuring all children, including those with disabilities, have access to free and appropriate public education (FAPE)

Question 5

Functional limitation

Answer 5

part of Nagi model; loss of a system is sufficient to prevent the performance of routine tasks by an individual, such as performing activities of daily living (ADLs), independently and in a timely manner

Question 6

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Answer 6

protects confidentiality of patient medical information and records when stored, when discussed by healthcare providers, and as they are conveyed between health-care providers or between healthcare providers and insurers

Question 7

Impairment

Answer 7

part of Nagi model; the body cannot compensate or heal itself, so the individual sustains loss of normal function of a body system

Question 8

Individually identifiable health information (18 HIPAA identifiers that are “protected information”

Answer 8

eighteen specific identifiers that are protected information for purposes of confidentiality

Question 9

Individuals with Disabilities Education Act of 1990 (IDEA)

Answer 9

replaces the EHA, and extends services to infants and toddlers

Question 10

International Classification of Function (ICF) model

Answer 10

a model of health and function generated by the World Health Organization (WHO) that considers a person’s health influences, and is influenced by, any disease or disorder that affects body functions and structures

Question 11

Nagi model

Answer 11

a model of health and function with four sequential phases

Question 12

National Center for Medical Rehabilitation Research (NCMRR) classification model

Answer 12

a disablement model derived from both the Nagi and World Health Organization models

Question 13

Patient Protection and Affordable Care Act of 2010 (ACA)

Answer 13

commonly called the Affordable Care Act, or ACA, provides major health care reform and access, which among other elements requires that hospitals provide patients with a copy of the Patient’s Bill of Rights

Question 14

Patient’s Bill of Rights

Answer 14

a list of guarantees for those receiving medical care

Question 15

Rehabilitation Act of 1973 (504 Act)

Answer 15

commonly called the Affordable Care Act, or ACA, provides major health care reform and access, which among other elements requires that hospitals provide patients with a copy of the Patient’s Bill of Rights

Question 16

Riser height

Answer 16

vertical dimension that separates one stair tread from the next stair tread

Question 17

Tread depth

Answer 17

horizontal dimension of a stair

Question 18

What are some examples of the purposes of patient care?

Answer 18

Patient care is intended to enhance function, participation in society (work/school and leisure), and the quality of life for patients.

Question 19

What is the family-centered model of the healthcare practitioner and patient/client relationship?

Answer 19

Recognizing that patients do not exist in isolation, a family-centered model acknowledges the importance of the context in which a patient’s care is provided. This context includes, but is not limited to, the patient’s family members, culture, roles in family and society, and home/work/school/leisure environments. In this model, healthcare professionals function as team members whose roles and importance change in response to the needs of patients and their families.

Question 20

What are the components of the International Classification of Function (ICF) model?

Answer 20

The IFC model which considers that a person’s health influences, and is influenced by, any disease or disorder that affects body functions and structures. Changes in body functions and structures may cause limitations in activities and social participation. Contextual factors include a patient’s personal factors and the environment in which the patient lives, works/attends school, and plays. All phases of the ICF model combine to affect a person’s quality of life.

Question 21

What are some of the benefits gained through acts to permit free and appropriate education of children with disabilities?

Answer 21

The Rehabilitation Act (often referred to as the504 Act) addresses civil rights of individuals with disabilities. Section 504 of the act created and extended civil rights to people with disabilities. The act itself addresses two major issues: (1) the provision of reasonable accommodations, and (2) a specification that no federal funding may be received by any entity that excludes the participation of qualified individuals solely on the basis of disability.
The Education for All Handicapped Children Act (EHA) focuses on ensuring all children, including those with disabilities, have access to free and appropriate public education (FAPE). A major requirement of this act mandates children receive education in the least restrictive environment, resulting in children with disabilities being educated along-side children without disabilities to the greatest extent possible. Schools are required to provide necessary services, such as occupational, physical, and speech therapy services to provide the assistance disabled children need to be successful. Parent rights are addressed by requiring parent participation in development of individualized education programs (IEPs) for each child.
The EHA was replaced with the Individuals with Disabilities Education Act (IDEA), which extends services to infants and toddlers. Early intervention (EI) services are recognized as providing the most significant opportunity to improve outcomes. Services for infants and toddlers are provided in a natural, patient-and family-focused environment. The Individuals with Disabilities Education Improvement Act (IDEA) of 2004 (PL 108-446) amended the IDEA of 1990. The Rehabilitation Act of 1973, in conjunction with the EHA and IDEA provides individuals with disabilities opportunities to have a better quality of life and to participate in society. These laws improved the public’s perception of disability and accessibility, providing opportunities for people with disabilities to be accepted and to participate more fully in society.

Question 22

What are the purposes of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?

Answer 22

The primary purpose of HIPAA is to standardize the exchange of financial and administrative data, while ensuring each patient’s health information is properly protected and to avoid confidential patient information being revealed or used inappropriately.
HIPAA established requirements for the storage and dissemination (electronic, written, or oral) of patient information between healthcare providers and between healthcare providers and insurers.

Question 23

What are the 18 identifiers used in medical records specific to the HIPAA?

Answer 23

Names/initials
All geographic identifiers smaller than a state, including county, city, street address, precinct, zip code, and their equivalent geocodes
All elements of dates (except year) directly related to an individual; all ages 90 years and above; and all elements of dates (including year) indicative of such age (except for aggregate categorization of ages 90 and above)
Telephone numbers
Fax numbers
Electronic mail addresses
Social Security numbers
Medical record numbers
Health-plan beneficiary numbers
Account numbers
Certificate and license numbers
Vehicle identifiers and serial numbers, including license plate numbers
Medical device identifiers and serial numbers
Internet universal resource locators (URLs)
Internet protocol (IP) addresses
Biometric identifier including fingerprints and voice prints
Full-face photographic images and any comparable images
Any other unique identifying number, characteristic, or code, except that covered identities may, under certain circumstances, assign a code or other means of record identification that allows de-identified information to be reidentified

Question 24

Why are these patient identifiers protected by the HIPAA?

Answer 24

To provide full confidentiality, none of the 18 identifiers can be released without a patient’s written permission.

Question 25

What are the rights and responsibilities outlined in the Patients’ Bill of Rights?

Answer 25

Provides coverage to Americans with preexisting conditions
Protects a patient’s choice of doctors
Young adults under 26 may be eligible for coverage under their parents’ health plan
Ends lifetime limits on coverage for all new health insurance plans
Ends pre-existing condition limitations/exclusions for children under 19
Ends arbitrary withdrawals of insurance coverage
Requires insurance companies to justify publicly unreasonable rate hikes
Requires insurance premium dollars to be spent primarily on health care, and not administrative costs
Restricts annual dollar limits on coverage by 2014
Removes insurance company barriers to emergency services so patients can seek emergency care at a hospital outside their health plan’s network.

Question 26

What are the specific requirements for ramps as presented in the Americans with Disabilities Act of 1990 (ADA)?

Answer 26

Any portion of an accessible route with a grade greater than 1:20 (5%) must be considered a ramp. Transitions of greater than 0.5 inch between two connected surfaces require a ramp. Ramps must use the least grade possible, and the grade may not be greater than 1:12 (8.3%) for new construction. A landing is required when a ramp has a continuous vertical rise exceeding 30 inches in height. For existing construction, two criteria apply when a grade of 8.3% cannot be achieved. First, a ramp with a grade of 1:10 (10%) is allowable as long as vertical rise is limited to 6 inches or less before a landing is provided. Second, a ramp with a grade of 1:8 (12.5%) is allowable as long as the vertical rise is limited to 3 inches or less before a landing is provided. Ramps must have a cross grade no greater than 1:50 (2%). Ramp width must not be less than 36 inches.

Question 27

Active listening

Answer 27

techniques used to promote effective communication

Question 28

Audit

Answer 28

systematic reviews of documentation that examine the efficacy and efficiency of patient-care outcomes with respect to interventions used

Question 29

Chart review

Answer 29

review of a patient’s chart prior to interacting with the patient

Question 30

Closed-ended questions

Answer 30

used to obtain or confirm specific information and often answered with a single word or a brief phrase

Question 31

Diagnosis

Answer 31

assignment of a label that states the categorization or classification of a patient’s problems; physical therapists diagnose based on the practice pattern or diagnostic cate-gory that most closely describes a patient’s impairments and functional limitations as presented in the Guide to Physical Therapist Practice

Question 32

Discharge plan

Answer 32

plan indicating duration of care, referrals and follow-ups, and equipment requirements; a plan to obtain necessary equipment for a patient to achieve goals

Question 33

Documentation

Answer 33

medico-legal record of patient care provided by all practitioners for a given patient

Question 34

ECHOWS

Answer 34

a physical therapist’s patient-interview assessment tool

Question 35

Effective communication

Answer 35

characterized by being timely, accurate, appropriate, clear, precise, concise, and organized

Question 36

Episode of physical therapy

Answer 36

all physical therapist services provided without a break in care for a given condition or problem

Question 37

Evaluation

Answer 37

process whereby physical therapists use examination data, professional knowledge, and clinical judgment, to identify impairments and functional limitations and generate diagnoses, prognoses, and a plan of care

Question 38

Examination

Answer 38

process of generating a patient/client history, reviewing all physiologic systems, and applying tests and measures

Question 39

Explanatory model

Answer 39

an approach to develop an under-standing of a patient’s perspective or explanation of their condition

Question 40

Feedback

Answer 40

information provided after performing an activity

Question 41

Short-term goals (STGs)

Answer 41

more discrete activities a patient will achieve to perform functional activities stated as long-term goals

Question 42

Long-term goals (LTGs)

Answer 42

statements describing functional capabilities a patient will have on discharge

Question 43

Instructions

Answer 43

inform patients of what is to be done and provide information as part of the teaching process; may include oral description, visual demonstration, and written description

Question 44

Intake form

Answer 44

form completed by patient prior to patient interview

Question 45

Interventions

Answer 45

services provided based on plan of care; may include treatment, communication, education, and planning

Question 46

Open-ended questions

Answer 46

allows a patient to tell his or her story in his or her own words

Question 47

Outcomes

Answer 47

functional capacity of a patient/client at discharge

Question 48

Plan of care

Answer 48

statement that specifies outcomes, interventions to be provided to achieve the stated outcomes, and a timeline for reaching the stated outcomes

Question 49

Preferred practice patterns

Answer 49

element of evidence-based patient management for specific diagnoses that guides management of patients but does not prescribe specifics of patient/client management

Question 50

Prognosis

Answer 50

determination of an optimal level of improvement and the time necessary to achieve projected outcome

Question 51

Red flag

Answer 51

a sign or symptom noted that does not fit with a known medical diagnosis for the specific patient

Question 52

Signs

Answer 52

objective evidence of disease perceptible by a health-care provider and reported in the objective data

Question 53

Subjective

Answer 53

documentation of relevant data concerning the patient’s history that are not verifiable in medical records; includes the patient’s description of functional problems, pain, and the date of onset; could also include patient’s name, gender, age and date of birth, primary and secondary diagnoses, and physicians

Question 54

Objective

Answer 54

documentation that includes the verifiable data such as: examination results, observations by healthcare providers, interventions, and patient response to interventions

Question 55

Assessment

Answer 55

analysis of data about a patient

Question 56

Plan

Answer 56

documentation of the plan of care developed by the physical therapist for providing patient treatment

Question 57

Symptoms

Answer 57

subjective perceptions of patients that may be indicative of disease

Question 58

Systems review

Answer 58

brief or limited examination of (1) the anatomical and physiological status of the cardiovascular/ pulmonary, integumentary, musculoskeletal, and neuromuscular systems and (2) the communication ability, affect, cognition, language, and learning style of the patient

Question 59

Tests and measures

Answer 59

examination methods to obtain objective data pertaining to a patient

Question 60

Verbal cues

Answer 60

auditory cues to patients that are provided during activity performance

Question 61

Yellow flag

Answer 61

risk factors indicating to proceed with caution because of the potential for adverse effects

Question 62

What are the elements of the Patient/Client Management Process presented in the Guide to Physical Therapist Practice (Guide)? Describe each.

Answer 62

Physical therapist patient/client management is individualized through implementation of six elements:
- Examination: collect data about the pt by reviewing chart information, when available, conducting an interview, completing a systems review, and conducting selected tests and measures
- Evaluation: using clinical judgement, evaluate data collected during the examination process to determine appropriate actions
- Diagnosis: using clinical judgement and information gained from the eval, determine the movement system dx and identify the related practice pattern
- Prognosis (including plan of care): based on the identified movement system dx and the examination data about the pt, determine the optimum outcomes that can be expected from interventions and the timeframe to achieve the outcomes; design POC to achieve prognosis
POC includes goals, frequency of interventions, duration of intervention, parameters of specific interventions, plans to obtain pt personal equipment, pt education, and referral to other providers
- Intervention: provide interventions included in POC to achieve the optimum pt outcomes; re-examine and re-eval is conducted as patient progress through POC
- Outcomes: include reductions in impairments, activity limitations, and social participation as described in the POC

Question 63

What types of information are obtained during initial patient interviews?

Answer 63

This includes chart review, review of intake forms, interview, systems review, tests, and measures.
Intake history in medical charts usually contains information about (1) general patient demographics, (2) current condition or chief complaint, (3) medical/surgical history, (4) general health status, (5) social history, (6) family history, (7) social health habits, (8) previous and present functional status, (9) medications, and (10) clinical tests ordered and their results.

Question 64

What are open-ended and close-ended questions? Provide examples for use during patient interviews.

Answer 64

Open-ended questions allow patients to tell their story in their own words and cannot be answered with a simple “yes” or “no.” This type of question allows physical therapists to direct the interview in a number of ways: (1) to explore, “Can you tell me more about it?” or “What problems are you having?”; (2) to encourage the patient, “And then what happened?”; (3) to focus an aspect of the interview, “I would like to clarify this aspect … ?”; and (4) to paraphrase for clarity, “Am I correct in saying that you feel … ?”

Closed-ended questions are used to focus the discussion and to obtain or confirm specific information. Closed-ended questions: (1) allow for “funneling” of information from very general to very specific responses; (2) are often used most effectively as follow-up on responses from open-ended questions; (3) can be answered with a single word or a brief phrase, such as “Yes,” “No,” or “Yes, once or twice before”; and (4) elicit specific information patients may not have thought to include. An example of a closed-ended question is: “Have you ever had this pain before?”

Question 65

What are the purposes for open-ended and close-ended questions used in patient interviews?

Answer 65

Open-ended questions allow patients to tell their story in their own words and cannot be answered with a simple “yes” or “no.”
Closed-ended questions are used to focus the discussion and to obtain or confirm specific information.

Question 66

What are the purposes of documentation in the healthcare system?

Answer 66

Documentation is a recording of data about patients, care provided, the provider of care, and results of care, entered into the patient’s medical record immediately following such actions.
Events and actions must be documented and are deemed not to have occurred if not documented. A patient’s medical record serves as a repository of pertinent information concerning the patient’s history, condition(s), and treatment and is a legal document.

Question 67

What are the requirements of adequate documentation of healthcare provider–patient interactions?

Answer 67

Documentation must be timely, accurate, appropriate, clear, precise, concise, organized, complete, and legible. Accurate documentation requires that recorded information be correct. Precise documentation requires that recorded information be provided in terms that state exactly what is intended to be conveyed. Concise documentation requires that information be organized effectively, conveying important information in a brief, clear, and unfettered fashion. Only relevant information is to be included. Complete documentation requires that all necessary information be included. Legible documentation requires that written, printed, or electronic media chart entries can be read easily. Timely documentation requires that notes be entered into the medical record as required by rule or regulation.
Written notes should be entered using nonerasable ink. Corrections are made by drawing one line through the error, and the initials of the practitioner and date of correction are entered above the correction. When additions are made within existing notes, an inverted “V” (∧) is used to indicate where the addition is made, and the initials of the practitioner and date of addition are entered above the existing text and before the addition.

Question 68

What are the similarities and differences between the two formats of medical records: discipline-specific medical record and problem-oriented medical record?

Answer 68

In the source-oriented method, charts are divided into sections for each healthcare profession providing service for a patient (e.g., clinical lab results, physical therapy notes, physician notes, dietary or nursing notes). The source-oriented system segregates patient information by discipline, necessitating that all healthcare providers review all discipline-specific sections of the record. A narrative format is usually used for writing notes in source-oriented charts.
The Problem-Oriented Medical Record (POMR) system was designed to facilitate care provided to patients by organizing each medical record in a format based on identified patient problems, rather than by professional discipline. The POMR is composed of (1) database, (2) problem list, and (3) notes. In the POMR system, the Subjective–Objective–Assessment–Plan (SOAP) format is used for note writing.

Question 69

What are the similarities and differences between the two formats of documentation within the medical record: SOAP note format and Guide note format?

Answer 69

Narrative notes can be unstructured, so headings and subheadings may or may not be used to organize information. The complexity and detail required in initial, evaluation, progress, and discharge notes may be difficult to achieve when using the narrative format.
The SOAP acronym denotes section headings in the note: (1) Subjective, (2) Objective, (3) Assessment, and (4) Plan. Each section of the SOAP note need not be included in every note. Initial notes, however, should include all sections.

Question 70

What resources are available to assist with meeting Medicare requirements for documentation?

Answer 70

Conditions of coverage for patients requiring physical therapy services
- Patient is under the care of a physician/NPP who is certified to approve plans of care.
- Services are required because of medical necessity.
- Plans for services developed by physical therapists must be certified by a physician.
- Physician recertification of plans of care for therapy services must occur every 30 days.
- Physical therapy services must be of a complexity that requires the clinical decision-making skills of a physical therapist and the intervention skills of either physical therapists or physical therapist assistants.
- Physical therapy services may only be rendered by physical therapists or physical therapist assistants under the supervision of a physical therapist.

Contents of Physical Therapy Plans of Care
- Each patient’s Plan of Care must be consistent with evaluation results.
- Diagnosis.
- Long-term treatment goals.
- Services are of appropriate type, frequency, intensity, and duration for the individual needs of the patient.

Documentation requirements
- Consistently and accurately reported.
- Legible, relevant, and sufficient to justify services.
- Evaluation and Plan of Care.
Certification.
- Indication of active participation by a physical therapist during each progress report period.
- Progress reports shall be at least once every 10 treatment days, or within one certification cycle.
- Complete progress reports shall be written by physical therapists.
- Physical therapist assistants may write certain elements of progress reports.
- Treatment/daily notes for each treatment day.
- Treatment/daily notes may be written by either a physical therapist or physical therapist assistant.

Question 71

How do medical records audits contribute to quality patient care?

Answer 71

A partial list of information a physical therapy departmental audit may yield is whether:
- Individual physical therapists are following departmental policies and procedures relating to documentation.
- Interventions being implemented are appropriate to diagnosis and goals for the patient.
- Patients achieve expected outcomes.
- Changes in departmental policy or procedures are necessary.
- Changes in treatment protocols are necessary.
- Continuing education is necessary to improve patient care skills.

Question 72

What are the purposes and characteristics of instructions, verbal cues, and feedback?

Answer 72

Instructions inform patients what is to be performed and provide information as part of the teaching process. Instructions may include oral description, visual demonstration, and written description.

Verbal cues are auditory cues to patients and are provided during activity performance. Prior to activity performance, patients should be instructed about the verbal cues that will be provided during activity performance.

Feedback is provided after performance of an activity. In the early learning of an activity, feedback is given about how well the skill was performed, followed by instruction on ways to improve performance.