Quiz 1 Chpt 1

Question 1

Describe what is meant by the following rule: “If it isn’t written, it didn’t happen.”

Answer 1

Means that anything that isn’t recorded can not be used later for reference when dealing with the law, insurance, or patient progress.

Question 2

Describe why the note in Figure 1–1 (old way of documentation before Medicare in mid 1960’s) is not an appropriate record by today’s documentation standards.

Answer 2

It doesn’t show detailed information of physical therapy services or practices.

Question 3

Identify the three major factors currently influencing the provision of health-care services and PT and PTA responsibilities.

Answer 3

1. Physical Therapy referral changes
2. Establishment of insurance reimbursement (Medicare,HMO,PPO, and other 3rd party payers)
3. Development of documentation classifications & models

Question 4

Describe the changes in the process for obtaining a referral for physical therapy that have occurred since the early 1960s.

Answer 4

• PT prescriptions ; now have more autonomy instead of direct following of physician orders.
• PT able to evaluate and treat; now have more autonomy with M.D.’s orders to “evaluate and treat”.
• Direct Access to Physical Therapy; direct access to Medical system straight through PT.

Question 5

Discuss how changes in the process for obtaining a referral for physical therapy influenced the evolution of the responsibilities of the PT and the PTA.

Answer 5

• Since being able to have more autonomy the PTs became more administrative while PTA’s took on more PT responsibilities.

Question 6

Describe three purposes for which the medical record is reviewed or audited.

Answer 6

1. Quality Assurance
2. Research/Education
3. Reimbursement

Question 7

Who determines standards or criteria for documentation?

Answer 7

Federal/State Government (FSBPT)
Professional Associations (APTA)
Accrediting Agency (CAPTE)
Healthcare Facilities (PT Clinics)

Question 8

Explain why the PTA could use the rule “follow the policies and procedures at the facility where you work.”

Answer 8

Because all facilities will still incorporate professional and legal standards and criteria.

Question 9

What is the importance of the ICF framework in documentation?

Answer 9

Because it’s a common universal language used by medical professionals within the rehab/medical setting

Question 10

Explain the differences between the Nagi Disablement Model and the ICF framework.

Answer 10

The Nagi disablement Model shows the correlation between impairment and functional limitations.
The ICF framework provides uniform standard of language for health issues

Question 11

Define documentation. Give an example of how it is used in physical therapy…

Answer 11

A recorded data/paper that is based on reliable proof or support of something.