Quiz 1b

Question 1

5 general uses of documentation

Answer 1

1. Pt care record
2. Admin mgt purposes
3. Reimbursement
4. Legal records
5. Research

Question 2

The Guide focuses on ___________________ as a measure of change

Answer 2

Functional status

Question 3

HIM

Answer 3

Health info management

Question 4

AHIMA

Answer 4

Health info management association

Question 5

CMS(HCFA)

Answer 5

Center for medicare/medicaid services

Question 6

Difference between medicare and APTA documentation guidelines

Answer 6

APTA more extensive; history, tests and measures, goals, etc

Question 7

6 documentation formats

Answer 7

1. Narrative
2. SOAP
3. HCFA(CMS) 700 - medicare
4. SF36
5. General hospital IP/OP forms
6. Guide template

Question 8

3 types of documentation

Answer 8

1. Initial eval
2. Progress
3. D/c

Question 9

Should be a part of every note and session

Answer 9

Pain assessment and management

Question 10

When are goals written?

Answer 10

IE

Question 11

Goals are updated ________ and ________

Answer 11

In progress notes; at d/c

Question 12

SMART objectives

Answer 12

Specific 
Measurable 
Achievable
Realistic
Time bound

Question 13

Goals should always align with ________________

Answer 13

Problem list

Question 14

Goals can be based on any of the benchmark levels of _______

Answer 14

ICF

Question 15

ABCDE Method

Answer 15

1. Audience/actor
2. Behavior
3. Condition/context/circumstances
4. Degree
5. Expected time

Question 16

Interval of time that you are treating a patient

Answer 16

Episode of care

Question 17

Time frame of goals are limited to the _____________

Answer 17

Episode of care

Question 18

_____ prepare pt for more functional ______

Answer 18

STG; LTG

Question 19

Manually you are taking up at least 25% of pts BW

Answer 19

MinA

Question 20

50% you/50% pt

Answer 20

ModA

Question 21

75%-100% you

Answer 21

MaxA

Question 22

Your hands are on pt; helping some

Answer 22

Contact guarding

Question 23

Goals for impairments must also be ___________

Answer 23

Measurable

Question 24

SOAP

Answer 24

Subjective
Objective
Assessment
Plan

Question 25

6 things written prior to start of SOAP components

Answer 25

1. Dx
2. Demographics
3. PMH
4. Past surgical history
5. Test results
6. Chart review

Question 26

Part of soap notes reported by pt

“Patient says….states…..reports”

Answer 26

Subjective

Question 27

Anything you do with the pt; posture, body language etc

Answer 27

Objective

Question 28

3 parts of assessment (SOAP)

Answer 28

1. Dx
2. Synopsis of pt status
3. Prognosis

Question 29

4 components of plan (SOAP)

Answer 29

1. Goals
2. Outcomes
3. Intervention plan
4. D/C plan

Question 30

When documenting, signature should include _

Answer 30

License number

Question 31

Color ink for documenting

Answer 31

Black

Question 32

Common term: weakness

Answer 32

Strength deficit

Question 33

Common term: deconditioned

Answer 33

Functional strength deficit

Question 34

Common term: walking

Answer 34

Gait training

Question 35

Common term: practiced

Answer 35

Instructed

Question 36

Common term: declined

Answer 36

Functional regression

Question 37

Common term: reminders

Answer 37

Verbal cues

Question 38

Common term: difficulty walking

Answer 38

Gait deviation

Question 39

Common term: endurance

Answer 39

Functional activity tolerance

Question 40

Common term: exercises

Answer 40

Exercise prescription

Question 41

Maintain; new phase of progression

Answer 41

Restorative

Question 42

Prevent/slow down deterioration

Answer 42

Skilled maintenance

Question 43

5 things to always remember

Answer 43

1. Skilled, medical necessity, reasonable progress
2. FUNCTION
3. Progress
4. Safety
5. Skilled services