Test 1: Module 1 (Patient Management/Documentation)

Question 1

Define Physical Therapist

Answer 1

Health professionals who diagnose and manage movement dysfunction as it relates to the restoration, maintenance, and promotion of optimal physical function and the health and well-being of individuals, families, and communities.

Question 2

What do PT’s do?

Answer 2

based on the person’s diagnosis, prognosis, and goals; PTs design and implement a customized plan of care in collaboration with the individual to achieve their goal directed outcomes

Question 3

Levels of Care

Answer 3

Primary care
Secondary care
Tertiary care

Question 4

Primary care

Answer 4

is defined as the provision of integrated, accessible health-care services by clinicians who
are accountable for addressing a large majority of personal health-care needs, developing a sustained partnership with patients, and practicing within the context of family and community.

(Usually MD/DO but can be a PT)

Question 5

Secondary care

Answer 5

is the care provided to patients who are initially treated by other practitioners and then referred to specialists/physical therapists

(Usually where PTs land)

Question 6

Tertiary care

Answer 6

is the care provided to patients in highly specialized, complex, and technology-based settings (e.g., burn units) or in response to requests of other health-care practitioners for consultation and
specialized services.

(Specialized care services)

Question 7

Prevention

Answer 7

is the avoidance, minimization, or delay of the onset of impairment, activity limitation, and/or
participation restrictions.

Includes primary, secondary, and tertiary prevention initiatives for individuals as well as selective intervention initiatives for subsets of the population at risk for impairments, activity limitations,
and/or participation restrictions

Question 8

Primary prevention

Answer 8

prevention prevents a target condition in a susceptible or potentially susceptible population through specific measures such as general health efforts.

(ex smoking causes heart disease, preventing smoking is primary prevention)

Question 9

Secondary prevention

Answer 9

decreases the duration of illness, severity of disease, and number of sequelae through early diagnosis and prompt intervention

(ex diabetes caught early, severity of disease decreased by weight loss intervention)

Question 10

Tertiary prevention

Answer 10

limits the degree of disability and promotes rehabilitation and restoration of function in patients with chronic and irreversible diseases

(ex diabetes causes heart disease, so preventing comorbidities associated with diabetes)

Question 11

Clinical reasoning

Answer 11

refers to the thinking and decision-making processes that are used in clinical practice.

• Reasoning is a context-dependent way of thinking and making decisions in professional practice to guide practice actions.

-It is a multidimensional, nonlinear cognitive process that involves synthesis of information and collaboration with the patient, caregivers, and health-care team.

• The clinician integrates information about the patient, the task, and the setting to reach decisions and determine actions in accordance with best available evidence

Question 12

Clinical Decision-making

Answer 12

is a shared process between the clinician and patient. Each of them brings their characteristics including their beliefs and biases, preferences, and values.

• The outcomes of the iterative clinical reasoning process
• Influenced by patient goals, clinician knowledge base, psychosocial skills, problem-solving strategies, and procedural skills

Question 13

Possible steps with clinical decision-making

Answer 13

Refer
Co-manage
Consult
Direct/supervise

Question 14

Elements of the patient management plan

Answer 14

History
Systems Review
Examination
Evaluation/Diagnosis
Prognosis
Plan of Care
Outcome

Question 15

Movement science

Answer 15

foundational for physical therapist practice. Includes biomechanics, kinesiology, psychology, and neuroscience.

Motor control and motor learning are distinct areas of study within the field of movement science.

Question 16

Movement system

Answer 16

defined in APTA’s vision statement as:

“a collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and
musculoskeletal) that interact to move the body or its component parts”

Question 17

HISTORY AND INTERVIEW

Answer 17

An element of the patient management plan

• Gather information about the patient’s history and current health status
• Initial interview sets the stage for shared decision making. Used to obtain info from patient, including goals, establish rapport/mutual trust, open communication, and motivation (building therapeutic alliance)

Question 18

SYSTEMS REVIEW

Answer 18

An element of the patient management plan

Screening examination (brief systems review) allows the therapist to quickly scan the patient’s body systems and determine areas of intact function and dysfunction.

• Cardiovascular
• Pulmonary
• Integumentary
• Musculoskeletal
• Endocrine
• Neuro/Neuromuscular

Question 19

EXAMINATION

Answer 19

An element of the patient management plan

Purpose is to collect baseline data on participation and activity that will be used to determine clinical outcomes of the episode of care.

Question 20

EVALUATION

Answer 20

An element of the patient management plan

PT interprets:

• Information from examination (movement analysis, measures, observations, and history/examination data)
• Information related to things that could positively (facilitators) or negatively (barriers) impact outcomes (environmental, financial, personal, etc.)

Question 21

DIAGNOSIS

Answer 21

An element of the patient management plan

The physical therapy diagnostic process (differential diagnosis) requires the clinician to collect, evaluate, and categorize data
according to a classification scheme relevant to the clinician and to determine whether the patient’s presenting problems are
amenable to physical therapy intervention.

PT diagnosis: movement function/dysfunction

(ex dependent mobility and ADL with impaired motor function and sensory integrity affecting the left nondominant side)

Medical diagnosis: refers identification of disease, disorder, or condition (pathology/pathophysiology) primarily at cell, tissue, or organ level

(ex Cerebrovascular accident)

Question 22

PROGNOSIS

Answer 22

An element of the patient management plan

Forecast of the likely course of the disease or ailment based on all the information gathered previously in the patient management plan

Question 23

PLAN OF CARE

Answer 23

An element of the patient management plan

POC outlines anticipated patient management

Question 24

ICF

Answer 24

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH

WHO’s International Classification of Functioning, Disability, and Health (ICF) provides a model and
common language by which to describe health conditions and organize information to classify patient’s problems by clearly defining the complex interaction among health condition, body function/structure impairment, activity limitation, participation restriction, and contextual factors

Question 25

Medically Necessary

Answer 25

healthcare services or supplies needed to diagnose or treat an illness, condition of disease, or its symptoms that meet the accepted standards of practice

Question 26

Skilled Care or Skilled services

Answer 26

if the intervention does not require the skills of a PT or a PTA supervised by the PT, then it is not considered skilled.

If our Plan of Care (POC) can be carried out by a person who is not skilled as a PT, then it is not skilled care

Question 27

Exceptions to the medically necessary and skilled care

Answer 27

Palliative care

Maintenance

Question 28

Types of PT documentation

Answer 28

• Narrative notes
• Problem Oriented Medical Record (POMR)
• SOAP Notes

Question 29

Narrative Notes

Answer 29

The intent is to describe in detail what happened during your encounter with the patient. There isn’t a lot of shorthand used and there are few to no “headings” separating topics. These notes are written in paragraph format and can be used for any type of interaction.

Question 30

Problem Oriented Medical Record (POMR)

Answer 30

organizes the information in the note by the patient’s problems.

each type of POMR formatted note starts off with a Problem List, basically a “Table of Contents”.

Question 31

SOAP Notes

Answer 31

S: Subjective - we usually say this includes anything the patient or their family or caregiver told us. But it also includes any information relevant to the case that another healthcare provider told us.

O: Objective: any outcome measure data we collected, any measurements we took, any description of “today’s treatment”, any documentation of the patient’s medical status or functional status that we observed - all Objective.

A: Assessment: Any thought we have about anything we measured or tested or observed. Our impression of our findings or interpretation of what our findings mean is our Assessment. In this section we assess what the measured impairments mean in terms of problems for the patient and create a problem list to guide our goal setting.
- Justify medical necessity

P: Plan: So what needs to be done to fix the patient’s problems? In “P” we describe what interventions you are going to utilize in your treatment, i.e., your Plan of Care, to facilitate progress of your patient towards their goals.
-Justify medical necessity

Question 32

ABCDEF format of writing STGs and LTGs

Answer 32

Audience = Who is doing this? Most often it is the patient, possibly a caregiver but it is NEVER the PT.

Behavior: What is the “thing” the patient is doing? The behavior is an action verb - the patient is ambulating, the patient is transferring, the patient is performing her HEP, etc.

Condition: Under what circumstances is the patient exhibiting this skill? Are they ambulating on level surfaces? stairs? With a walker?

Degree (intensity/need for assistance/ # of reps): How well can they do this? Can they ambulate 10 feet? 150 feet? Are they increasing their L knee flexion ROM from 60 degrees to 100 degrees? Are they doing the behavior independently? With min assist?

Expected Duration: How long will it take the pt to reach a goal? Usually includes frequency (how often will the pt be seen?) and duration (for how long?).

Function – they will accomplish this goal in order to what? Be independent in ADLs and iADLs? Be independent with community mobility? Return to work? Pick up their 2 year old? What function are we improving or restoring to normal? The FUNCTION is the reason we are doing everything else in our POC, to get here.