Midterm

Question 1

Interruption or interference with normal process. Simultaneous body efforts to heal itself or regain a normal state

Answer 1

Pathology

Question 2

Loss of an anatomical nature. How disease affects the body

Answer 2

Impairment

Question 3

Limitations in an individual’s ability to carry out a meaningful activity. (patient specific)

Answer 3

Functional limitation

Question 4

Limitations in performing socially defined roles expected of an individual

Answer 4

Disabilities

Question 5

Tasks an individual cannot do. Individual level

Answer 5

Activity limitation

Question 6

Rolls individual cannot do. Societal level

Answer 6

Participation restriction

Question 7

Three events that changed treatment and documentation responsibilities in physical therapy

Answer 7

1. Changes in referrals for PTD.
2. Establishment of Medicare.
3. Development of documentation classifications

Question 8

Three main purposes for reviewing medical records

Answer 8

Quality assurance, research and education, reimbursement

Question 9

Gathering subjective and objective info about the patient

Answer 9

Examination

Question 10

Clinical judgment PT makes based on exam

Answer 10

Evaluation

Question 11

Process and end result of evaluating exam data

Answer 11

Diagnosis

Question 12

Level of improvement patient may attain/ time needed

Answer 12

Prognosis

Question 13

Activities that make up a treatment plan

Answer 13

Intervention

Question 14

The consequences of disease as it pertains to the relationship between body structures, ability to carry out tasks, and ability to function within society

Answer 14

Disablement

Question 15

Used when patients progress is being reported to a physician

Answer 15

Letter format

Question 16

Within PT department to record patient’s treatment goals. Not part of the medical record

Answer 16

Cardex

Question 17

Listening for specific kinds of info

Answer 17

Analytic

Question 18

Listening for patients answer to specific questions

Answer 18

Directed

Question 19

Listening for general info to get the bigger picture

Answer 19

Attentive

Question 20

Pain scale 0 to 10 or 1 to 7

Answer 20

Verbal rating scale

Question 21

Patient marks on a line 0 to 10

Answer 21

Visual analog scale

Question 22

Describes pain using words

Answer 22

Checklists

Question 23

Uses symbols or colors to indicate pain and location

Answer 23

Body drawings

Question 24

Goal addresses impairment and activity steps towards long-term goals

Answer 24

Short-term goals

Question 25

Goal address is overall functional status, Previous level of function. Community/work as endpoint

Answer 25

Long term goal

Question 26

Goals for patient during a specific treatment session

Answer 26

Daily goal

Question 27

DEP

Answer 27

Data, eval, and performance goals

Question 28

PSPG

Answer 28

Problem status plan and goals

Question 29

PSP

Answer 29

Problem status and plan

Question 30

What are the six categories of documentation content

Answer 30

1. Problems
2. Data
3. Tx plan
4. Goals/outcomes
5. Administration of tx plan
6. Tx effectiveness

Question 31

Entities responsible for providing documentation standards

Answer 31

Fed and state gov

Professional associations

Accrediting agencies

Healthcare facilities