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(2) Musculoskeletal Examination > S1_L1: Documentation in PT > Flashcards

S1_L1: Documentation in PT Flashcards

1
Q

TRUE OR FALSE: Medical jargons are used in creating a concise documentation.

A

False

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2
Q

TRUE OR FALSE: All the positive findings are written before the negative findings in a concise documentation.

A

True

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3
Q

TRUE OR FALSE: Person-first language and abbreviations of medical terminologies are used in writing a concise documentation.

A

True

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4
Q

TRUE OR FALSE: Correcting an error in documentation is done by striking through the error, then writing “error” above it followed by the correct finding, signature, and date.

A

True

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5
Q

TRUE OR FALSE: Degrees and certification are important in the legibility of documentation.

A

True

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6
Q

TRUE OR FALSE: The Source-Oriented Medical Record-Keeping System (SOMR) is the more commonly used format of documentation.

A

False, it is the Subjective Objective Assessment Plan (SOAP).

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7
Q

TRUE OR FALSE: In documentation, leaving blank spaces is avoided.

A

True

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8
Q

TRUE OR FALSE: The progress notes are only done during the first PT session.

A

False, it’s initial evaluation

  • Progress notes are written after every PT session
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9
Q

TRUE OR FALSE: The initial evaluation notes are done before the patient goes back to MD for re-evaluation.

A

False, it’s re-evaluation notes

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10
Q

TRUE OR FALSE: The discharge notes / summary is done after the MD says patient achieved pre-injury level or is highly functional and therefore, can be discharged from PT.

A

True

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11
Q

Determine the corresponding descriptions of the subjective headings

  1. Accompanying illness, previous PT treatment
  2. Occupation, hobbies, vices
  3. Tests, labs, meds, rx related to the present complaint
  4. Architectural barriers, home set-up, furniture, distance, type of walking surfaces
  5. Includes pain, weakness, difficulty in moving, numbness, pins and needles sensation, and limited ROM of arm/neck/leg
  6. Family support, social support

A. Demographics
B. Chief Complaint (CC or c/o)
C. History of Present Illness (HPI)
D. Past Medical History (PMHx)
E. Lifestyle
F. Physical Environment
G. Social Environment
H. Patient’s Goal

A
  1. D
  2. E
  3. C
  4. F
  5. B
  6. G
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12
Q

Determine the corresponding subheading of the subjective findings

  1. Pt reported to fall on the floor c extended legs in a split position
  2. Hobby is dancing which he does q weekend
  3. Inability to walk & weight bear on (L) LE
  4. Denies any Hx of trauma, surgical operation, & hospitalization in the past.
  5. Lives c family in a 2-storey house c stairs ~15 steps c handrail on (B) sides.

A. Demographics
B. Chief Complaint (CC or c/o)
C. History of Present Illness (HPI)
D. Past Medical History (PMHx)
E. Lifestyle
F. Physical & Social Environment
G. Patient’s Goal

A
  1. C
  2. E
  3. B
  4. D
  5. F
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13
Q

Determine the corresponding subheading of the subjective findings

  1. Non-smoker & non-alcoholic beverage drinker
  2. To be able to walk again properly
  3. 22 y/o (-) Htn/DM, (R) handed ♂
  4. Pt was transported to Makati Medical Center through ambulance & underwent x-ray & MRI revealing (L) pulled hamstring
  5. X-ray showed (-) fx

A. Demographics
B. Chief Complaint (CC or c/o)
C. History of Present Illness (HPI)
D. Past Medical History (PMHx)
E. Lifestyle
F. Physical Environment
G. Social Environment
H. Patient’s Goal

A
  1. E
  2. H
  3. A
  4. C
  5. C
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14
Q

Determine the corresponding descriptions of the palpation grading

  1. Pain and wincing
  2. Refuses to be touched
  3. Pain
  4. Pain, wincing, and withdrawal

A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4

A
  1. B
  2. D
  3. A
  4. C
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15
Q

TRUE OR FALSE: Past Medical History does concern the present condition of the patient.

A

False

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16
Q

TRUE OR FALSE: Endomorph describes a lean body, that of a physically active individual.

A

False, it’s mesomorph

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17
Q

TRUE OR FALSE: Muscle tone, crepitations, tightness, muscle spasm, muscle guarding, edema, tenderness, nodules, taut bands all fall under the objective assessment known as palpation.

A

True

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18
Q

TRUE OR FALSE: Muscle spasm is noted even when the pt is at rest.

A

True

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19
Q

Tightness or contraction because of pain d/t movement

A

Muscle guarding

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20
Q

“Intact deep sensation as to proprioception, kinesthesia & vibration, except” is the heading for what objective assessment?

A

Sensory testing (Deep sensation)

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21
Q

“Intact sensation as to light touch, pain, pressure & temperature using cotton, pin, thumb & test tubes as modalities respectively on (B) UE/LE & trunk, except:” is the heading for what objective assessment?

A

Sensory testing (Superficial sensation)

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22
Q

“All major joints of (B) UE/LE are WNL, actively & passively done, pain free & c (N) end feel, except” is the heading for what objective assessment?

A

Range of motion measurement

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23
Q

“All landmarks are leveled, except:” is the heading for what objective assessment?

A

Postural analysis

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24
Q

“All major muscles of (B) UE/LE & trunk graded 5/5, except” is the heading for what objective assessment?

A

Manual muscle testing

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25
Q

“Indep in all aspects of ADLs, bed mobility & transfers, except:” is the heading for what objective assessment?

A

Functional Analysis

26
Q

What are the 2 ways of documenting deep tendon reflexes?

A
  1. Writing it down (e.g. O: DTR > Normoreflexive on (B) UE/LE
  2. Using figures
27
Q

TRUE OR FALSE: ++ means brisk response and normoreflexia

A

True

28
Q

TRUE OR FALSE: +++ is for clonus

A

False, it’s ++++

29
Q

Determine the corresponding descriptions of the sections of the SOAP

  1. Includes results of evaluation, diagnosis (PT Impression), and prognosis
  2. Includes patient’s symptoms in which the data are obtained from the patient interview
  3. Factual data gathered from the examination or assessment
  4. Includes signs
  5. Source of information could either be coming from the patient or the caregiver
  6. Conclusion reached about the patient’s problems

A. Subjective
B. Objective
C. Assessment
D. Plan

A
  1. C
  2. A
  3. B
  4. B
  5. A
  6. C
30
Q

A document is considered ___ when it measures what it is supposed to measure.

A

valid

31
Q

A document is considered ___ when it provides the exact same measurement each time. It is the repeatability of the measure.

A

reliable

32
Q

It serves as the foundation of documentation

A

International Classification for Functioning, Disability, and Health (ICF model)

33
Q

Any form of written communication related to patient encounter. It encompasses the preparation and assembly records to authenticate and communicate the care given by a healthcare provider and the reasons for giving that care.

A

Documentation

34
Q

Determine the corresponding objective subheading for the ff findings

  1. NDI, DASH, FIM, WOMAC
  2. Normoreflexive on (B) UE/LE
  3. Elevated (L) shoulder
  4. (R) Anterior Deltoid: Gr. 4/5
  5. Balance and tolerance

A. Ocular inspection
B. Palpation
C. Anthropometric measurement
D. Range of motion
E. Special tests
F. Sensory testing
G. MMT
H. Deep Tendon Reflex
I. Postural Analysis
J. Functional Analysis

A
  1. J
  2. H
  3. I
  4. G
  5. J
35
Q

Determine the corresponding objective subheading for the ff findings

  1. crepitations
  2. 6-minute walk test
  3. (+) Cozen’s test on (R)
  4. chest expansion
  5. (R) ankle eversion: 0 degrees

A. Ocular inspection
B. Palpation
C. Anthropometric measurement
D. Range of motion
E. Special tests
F. Sensory testing
G. MMT
H. Deep Tendon Reflex
I. Postural Analysis
J. Functional Analysis

A
  1. B
  2. J
  3. E
  4. C
  5. D
36
Q

Determine the corresponding classification for the ff findings in Ocular Inspection

  1. (+) hematoma on (R) thigh
  2. (+) bandage on (L) ankle
  3. (+) swelling on ant. aspect of (R) shoulder
  4. Ectomorph
  5. Alert, Conscious, Coherent, Cooperative, and Oriented as to person, place, time

A. Manner of arrival
B. Mental status
C. Body type
D. Attachment
E. Skin integrity
F. Swelling
G. Postural deviations
H. Gait deviations

A
  1. E
  2. D
  3. F
  4. C
  5. B
37
Q

Determine the corresponding descriptions of the manners of arrival

  1. pt is restricted to bed because of medical condition
  2. pt is in w/c when brought to clinic
  3. pt is in stretcher when brought to clinic
  4. pt is restricted to bed because of attachments
  5. pt is bed restricted following MD advice
  6. Amb c quad cane on (R)

A. Bed-ridden
B. Bed-bound
C. Bedfast
D. w/c-borne
E. Ambulatory c assist. device
F. Ambulatory s assist. device
G. Stretcher-borne

A
  1. A
  2. D
  3. G
  4. B
  5. C
  6. E
38
Q

modified T/F
A written documentation is based on patient encounter to authenticate, communicate the care given by the healthcare provider & reasons for giving that particular care

Doctors, PTs & supervisors, Pt.’s family, 3rd party payers (insurance) & the legal system needs the medical document

A

TT

39
Q

the ff are PURPOSES of DOCUMENTATION, EXCEPT:

A. Gather information to provide comprehensive Physical Therapy care to a patient or client

B. Review patient or client progress or status, make further healthcare decisions

C. External and Internal audits, record keeping, and clinical reviews

D. Verify claims of Physical Therapists & determine reimbursements for services rendered

E. None of the above

A

E

40
Q

what are the 2 ways of documenting

A
  1. The Source-Oriented Medical
    record-keeping system or the SOMR
  2. the Subjective Objective Assessment Plan or SOAP
41
Q

match the ff SOAP

  1. Includes patient’s symptoms in which the data are obtained from the patient interview
  2. The source of the information could either be coming from the PATIENT or the CAREGIVER
  3. Includes SIGNS where the PHYSICAL THERAPIST gathers the factual data from the examination or assessment
  4. Conclusion reached about the patient’s problems that Includes results of evaluation, diagnosis and prognosis
  5. Includes plan of care and intervention

A. Subjective
B. Objective
C. Assessment
D.Plan

A
  1. A
  2. A
  3. B
  4. C
  5. D
42
Q

match the ff PT notes

  1. it is the baseline whether there’s a progression/regressin in succeeding examinations
  2. done once during the first PT session (comprehensive SOAP)
  3. Done before pt. goes back to MD for re-eval
  4. done when MD orders pt. to be discharged
  5. done every after PT session to compare with previous progress notes /IE

A. Initial Evaluation (IE)
B. Progress Notes
C. Re-evaluationNotes
D. Discharge Summary

A
  1. A
  2. A
  3. C
  4. D
  5. B
43
Q

What serves as the foundation of documentation?

A

The INTERNATIONAL CLASSIFICATION FOR FUNCTIONING, DISABILITY AND HEALTH (ICF Model)

44
Q

which of the ff are the evidence-
based practices integrated when writing a clinical document?

A. Document test measures that are VALID and RELIABLE

B. Use standardized outcome measures

C. Select & Implement an appropriate plan of care based on research or clinical guidelines

D. All of the above

A

D

45
Q

which of the ff makes the PT document concise?

A. use of concise wording

B. use of Abbreviations & Medical Terminology

C. Use of template & avoiding leaving blank spaces

D. Use person-first language

E. All of the above

A

E

46
Q

modified T/F on Concise wording

Make all points CLEAR and SUCCINCT.

Omit unnecessary and irrelevant facts.

A

TT

47
Q

identify the Abbreviations & Medical Terminologies

  1. ROM
  2. od
  3. tx
  4. ant.
  5. bid
  6. MMT
  7. BUN
  8. MD
  9. rx
  10. stat.
A
  1. Range of motion
  2. once a day
  3. traction
  4. anterior
  5. bis in die (twice a day)
  6. manual muscle test
  7. blood urea nitrogen
  8. medical doctor
  9. treatment/prescription
  10. statim (urgent)
48
Q

modified T/F in using person-first language

Pt. claims pain started a wk. ago when doing laundry.

Pt. reports pain on the ant. aspect of the (R) shoulder graded 10/10 on the Subjective Pain Scale (SPS).

A

TT
both are in 1st person language
* avoid using he/she,I,them,they

49
Q

which of the ff are true on legibility of PT documentation

A. writing should be clear & readable

B. use of black/blue pen

C. write the word “error” then place the correct entry & counter sign then put the date

D. use of degrees & certification (MSPT, PT, PTRP)

E. all of the above

A

E

50
Q

which of the ff demographics are part of the 1st subheading of the subjective evaluation

A. Name (initials)
B. Age
C. Gender
D. Present General medical conditions (Htn, DM, Asthma)
E. Handedness
F. All of the above

A

F

51
Q

the ff are questions to be asked in the chief complaint, EXCEPT:

A. Pain? Weakness?

B. Limited movement of the arm or neck or leg?

C. Difficulty moving?

D. Numbness? Pins & needles sensation?

E. All of the above

A

E

52
Q

the subjective is divided into several subheadings, properly arrange them from top to bottom

A

Demographics

Chief Complaint

History of Present Illness (HPI)

Past Medical

History

Lifestyle

Physical & Social Environment

Patient’s goal

53
Q

modified T/F

avoid questions answerable by yes/no & leading questions

in HPI ask for test, labs, meds, rx, xray, CT scan, MRI, any physical exam, EMG-NCV, pain relievers as well as events related to injury such as falls, chronic overhead activity or dislocation

A

TT

54
Q

modified T/F

PMHx doesn’t concern present complain of pt but the relevant medical condition in the past or previous PT treatment

It is important to probe. pt to know if pt had previous injury

A

TT

55
Q

identify if HPI or PMHx

  1. pt has supraspinatus tendinitis & complains of shoulder pain because of supraspinatus tendinitis then this falls under ___
  2. if during interview, you found that pt. had shoulder dislocation then anything related to the previous condition which is shoulder dislocation under ___
A
  1. HPI
  2. PMHx
56
Q

modified T/F on Lifestyle

It is important to ask the pt’s occupation, vices such as cigarette smoking (how many sticks per day) & alcoholic beverage (frequency of drinking)

Ask if patient has hobbies like dancing (Anke sprain), basketball (ACL injury), pitchers (prone to shoulder dislocation), secretaries clerical workers (prone to CTS)

A

TT

57
Q

modified T/F

It is important to ask the pt’s family/social support (who lives with the pt)

It’s important to ask the physical environment of the pt like architectural barriers (overhead cabinets/furnitures), type of walking surface (cement/carpet), home & work set-up as well as distance from bedroom to CR or main door to bedroom

A

TT

58
Q

modified T/F

Pt’s goal is what the pt is expecting in terms of the present complaint at the end of the PT session

In the objective part, the first subheading is ocular inspection on the manner of arrival, body type, attachment, mental status, skin integrity, postural & gait deviations

A

TT

59
Q

match the ff

  1. bed restricted due to doctor’s advice
  2. bed restricted due to medical condition
  3. bed restricted due to attachments

A. bed bound
B. bed ridden
C. bedfast

A
  1. C
  2. B
  3. A
60
Q
  1. Lean delicate body build (very thin)
  2. Muscular body build (compact)
  3. soft round body build with high fat tissue

A. Ectomorph
B. Mesomorph
C. Endomorph

A
  1. A
  2. B
  3. C
61
Q

match the ff subheading

  1. Muscle tone, Warmth, Crepitations, Tightness, Muscle spasm, muscle guarding, Tenderness, Edema, Nodules,
    tautbands
  2. Limb girth, True & Apparent leg length, Stump Measurement, Chest Expansion
  3. active, passive, end feel
  4. (+) Empty can test, (+) Anterior
    Drawer test, (+) Hawkins- Kennedy test, (+) Cozen’s test
  5. superficial, deep & cortical sensation

A. palpation
B. Anthropometric Measurement
C. ROM
D. Special test
E. sensory testing

A
  1. A
  2. B
  3. C
  4. D
  5. E
62
Q

match the ff subheading

  1. (R) Supraspinatus 3/5, (L) shoulderflexors 4/5
  2. Normoreflexive on (B) UE/LE
  3. Anterior, Posterior & lateral view
  4. ADLs, bed mob, transfers, endurance
  5. balance & tolerance, OMTs (NDI, FIM)

A. DTR
B. MMT
C. postural analysis
D. functional analysis

A
  1. B
  2. A
  3. C
  4. D
  5. D

(2) Musculoskeletal Examination (11 decks)

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