Week 1

Question 1

List the components that must be documented in the prognosis. What terminology is to be used regarding the patient’s ability to achieve the predicted optimal level of function?

Answer 1

• predicted optimal level of improvement
• amount of time needed
• need explicit statement (excellent, good, fair, poor)

Question 2

Where is the prognosis documented in the initial evaluation/reevaluation?

Answer 2

POC or assessment

Question 3

When must you include a statement regarding rehabilitation potential? How is it documented?

Answer 3

medicare patient - documented like prognosis

Question 4

Why do you want to refrain from using the terms “fair” or “poor” as it relates to the patient’s prognosis

Answer 4

says that the patient is fit for PT

Question 5

How does the physical therapy prognosis differ from the medical prognosis?

Answer 5

PT - patient’s ability to achieve the predefined optimal level of function that we have outlined for them
Medical - timeline for recovery

Question 6

What components must be included in the plan of care (POC)?

Answer 6

• specific goals
• predicted level of optimal improvement/anticipated discharge plans
• general interventions to be used
• proposed duration and frequency

Question 7

List and define the 5 criteria for goal writing.

Answer 7

• patient-centered
• objective
• measurable
• functional
• time element

Question 8

Can you write a goal for an impairment that is not documented?

Answer 8

No

Question 9

How should the interventions to be used in a POC be documented?

Answer 9

indicate broad areas of interventions necessary in assessment

Question 10

What is important to keep in mind regarding writing the timeframes for frequency and duration?

Answer 10

• setting
• capacity of the patient to participate in POC
• patient transportation
• insurance restrictions

Question 11

When should you document progress?

Answer 11

every patient encounter

Question 12

What is a daily note?

Answer 12

brief summary of progress

Question 13

What is a progress report?

Answer 13

more detailed summary of progress included in daily note

- compares current status to previous timeframe

Question 14

what is a re-exam?

Answer 14

most detailed form of summary of progress

- re-test of initial exam measurements

Question 15

What is the main difference between a daily note and a progress report?

Answer 15

progress note is more specific detail and reference back to eval

Question 16

What conditions determine that a modification to the POC must occur? • What must be performed if the POC needs to be modified?

Answer 16

patient change of status has occurred

- reevaluation must be performed

Question 17

List the reasons that would warrant a PT to perform a Reexamination?

Answer 17

• unanticipated change in patient’s status
• failure to respond to PT intervention as expected
• need for a new POC and/or time factors based on insurance

Question 18

What are the components of a Reexamination?

Answer 18

• clinical impression or diagnosis
• objective measures
• goal status
• evaluation/assessment