Quiz 1 Chpt 4

Question 1

Compare and contrast the medical diagnosis and the physical therapy diagnosis.

Answer 1

Medical is a systemic pathology vs PT is a pathokinesiology diagnosis ( not medical)

Question 2

What is impairment? Give three examples.

Answer 2

Abnormalities/dysfunctions.
Examples include....
1. Muscle weakness
2. Stiff Joints
3. Inflammation of tendons (tendinitis)

Question 3

Define functional limitation.

Answer 3

What pt. is able or unable to due because of impairment.

Question 4

Explain the difference between a source-oriented and a problem-oriented medical record.

Answer 4

Source Oriented : Everything broken down by each discipline. Usually color coded.
Problem Oriented: Content of input for all medical info organized around the problem

Question 5

Define SOAP, PSPG, and DEP.

Answer 5

SOAP: Subjective, Objective, Assesment, and Plan
PSPG: Problem, Statis, Plan, Goal
DEP: Data, Eval, Performance

Question 6

List three formats in which documentation content may be presented, and identify the types of physical therapy facilities most likely to use each format.

Answer 6

Soap Notes; Used in almost all types of settings. Hospitals a lot due to accuracy.
Computerized Documentation; Most commonly used in Outpatient clinics
Letters; Commonly used in PT private practice

Question 7

What is an IEP and in which clinical setting is it used?

Answer 7

Individualized Education Program.

Used within school settings for students with disabilities

Question 8

List the six categories of documentation content and describe the content of each category.

Answer 8

1. The problem (requiring treatment)
2. Relevant data to diagnosis
3. Treatment Plan
4. Goals/Outcomes
5. Record of treatment administration
6. Effectiveness/Results