The APTA's Vision Statement is "Transforming society by optimizing movement to improve the human experience."

True

False

• True
• False

The following statement(s) is/are correct except:

• A very experienced PTA can interpret the data from the PT initial examination and evaluation.
• A very experienced PTA cannot interpret the data from the initial examination and evaluation, because only PTs can interpret the data from the initial PT examination and evaluation.
• A senior SLP cannot interpret the data from the initial examination and evaluation, because only PTs can interpret the data from the PT initial examination and evaluation.
• An OTR/L cannot interpret the data from the initial PT examination and evaluation, because only PTs can interpret the data from the PT initial examination and evaluation.

• A very experienced PTA can interpret the data from the PT initial examination and evaluation.

Identify the roles of a Physical Therapist and a Physical Therapist Assistant by matching

PT (physical therapist),

PTA (physical therapist assistant) or B (both):

• Perform initial evaluations
• Complete Plan of Care .
• Perform therapeutic interventions based on plan of care . Assess patient progress .
• Document data and interventions
• Perform re-examination
• Complete discharge summary

• (PT) Perform initial evaluations
• (PT) Complete Plan of Care .
• (PTA) Perform therapeutic interventions based on plan of care . (PTA) Assess patient progress .
• (PTA) Document data and interventions
• (PT) Perform re-examination
• (PT) Complete discharge summary

A meeting between the PT and the PTA to discuss a patients progress or lack of progress, is most commonly called:

• Supervisory meeting
• Staff/departmental meeting
• Strategic planning meeting
• None of the above

• Supervisory meeting

A PTA can ask a SW to help with all of the following except:

• To assess the patient's home environment and instruct the patient at discharge from the hospital
• To arrange for home health services at the patient discharged from the hospital
• To arrange for Meals-on-Wheals for a home-bound patient
• All of the above

• To assess the patient's home environment and instruct the patient at discharge from the hospital

PTAs were created by the APTA as a result of all of the following except:

• Development of the National Foundation for Infantile Paralysis
• Development of the Medicare program
• Development of the Medicaid program

• Development of the National Foundation for Infantile Paralysis

Multiple Answer: Select ALL of the following which identifies the role of a Physical Therapist Assistant:

• Perform select physical therapy interventions
• Follow the plan of care outlined by an Occupational Therapist
• Complete a discharge summary
• Assist with the data collection for an evaluation

• Perform select physical therapy interventions
• Assist with the data collection for an evaluation

In physical therapy utilization review, PTAs can review the work of the PTs.

True

False

• False

The first to use electrical stimulation of torpedo-fish for headaches:

• Hippocrates
• Leo Buerger
• Dr. Robert Lovett
• A. Gustav Zander

• Hippocrates

The PTA Caucus allows PTAs to provide higher input to the House of Delegates (HOD).

True

False

• True

A PTA can supervise a physical therapy aide to perform all of the following except:

• Transport the patient from his hospital room to the physical therapy department
• Clean the whirlpool
• Apply ultrasound treatment to the patient's lower back
• All of the above

• Apply ultrasound treatment to the patient's lower back

A patient who cannot cook or clean her home is considered to have a disability.

True

False

True

• In a SNF, the SPTA may be a member of:

A.an intradisciplinary team that is made up of PTs, PTAs, OTs, SLPs, PTA Aides

B.an interdisciplinary team that is made up of PTs, PTAs, PTA Aides

C.an interdisciplinary team that is made up of PTs, PTAs, PTA Aides, OTs, COTAs and SLPs

D.All of the above

• (C) .an interdisciplinary team that is made up of PTs, PTAs, PTA Aides, OTs, COTAs and SLPs

• Risk management is:
• is part of the facility's quality assurance that is implemented to achieve a high quality of care
• is part of the activities implemented in a clinical facility to defend against the threats posed by legal liability
• A and B
• None of the above

• A and B
• is part of the facility's quality assurance that is implemented to achieve a high quality of care
• is part of the activities implemented in a clinical facility to defend against the threats posed by legal liability

All of the following physical therapy interventions can be provided by the PTA in a school system except:

• Positioning in the wheelchair
• Developing the IEP
• Gait training with a walker
• None of the above

• Developing the IEP

In a Hospital, the PTA and an RN working and communicating towards a pt.'s wellbeing are members of:

• an intradisciplinary team
• an interdisciplinary team
• a care plan team
• a multidisciplinary team

• an interdisciplinary team

The APTA headquarters are in:

• Washington, DC
• Alexandria, VA
• Houston, TX
• None of the above

• Alexandria, VA

When working with the SPTA, the ultimate responsibility for physical therapy services is of:

• PTA
• PT
• PT and PTA equally
• PA

• PT

Planning to purchase an exercise machine for approximately $1500 can be included in the:

• Operating expense budget
• Capital expense budget
• Accounts receivable budget
• None of the above

• Capital expense budget

Donations to PT-PAC can help with future physical therapy favorable legislative actions on Capitol Hill?

True

False

• True

All of the following physical therapy interventions can be provided by the PTA in home health care except:

A.Implementation of a HEP

B. Bed mobility and transfers

C.Gait training

D.Re-evaluation of the patient every 4 weeks

E.Stretching program

D.Re-evaluation of the patient every 4 weeks

If a patient's medical status changes, the PTA must immediately request a meeting with:

• the supervising PT
• the supervising OT
• the supervising SLP
• the Rehab Director
• A and D only

the supervising PT

The first War Emergency Training Course of World War II for physical therapists was initiated at:

• New York Harbor hospital
• Lakewood hospital
• Fort McPherson hospital
• Walter Reed hospital

• Walter Reed hospital

Multiple Answer: A very experienced PTA as the Physical Therapy Director can perform all of the following:

• Set and apply policies and procedures
• Motivate PTs, PTAs, and other personnel
• Examine and evaluate patients
• Interview new personnel

• Set and apply policies and procedures
• Motivate PTs, PTAs, and other personnel
• Interview new personnel

As per the APTA, a PTA can perform all of the following duties except:

• Modify selected interventions to progress the patient
• Write a discharge plan
• Perform selected interventions
• Document patient progress

Write a discharge plan

In traditional outpatient therapy facilities (OT, SLP,PT), physical therapy services are provided within which of the following team models?

• intradiscipinary model
• multidisciplinary model
• interdiscipinary model
• transdiscipinary model

• interdiscipinary model

The following is a potential role of Physical Therapist Assistants in the healthcare industry:

• Staff therapist
• Supervising therapist of therapy aides
• Clinical instructor for student PTAs
• Physical therapy clinic manager
• All of the above

All of the above

The following are a setting in which a PTA may work except: Home Health

• Sub-acute Rehabilitation Hospital
• Public School
• All of the above are settings in which a PTA may work
• None of the above are settings in which a PTA may work

• All of the above are settings in which a PTA may work

All of the following are impairments except:

A.Patient is unable to brush their hair.

B. Muscle weakness

C. Muscle spasm

D. Edema

• (A) .Patient is unable to brush their hair.

Who is credited as being one of the first “physical therapist” in the United States?

• Melinda Rossi
• Jennifer Maclin
• Mary McMillan
• Ruth Pandolph

• Mary McMillan

A PTA can supervise a physical therapy aide performing which of the following:

• Clean the whirlpool
• Transport the patient from his hospital room to the physical therapy department
• Follow behind a therapist walking with a patient with the wheelchair as a precaution
• All of the above

• (C) All of the above
• lean the whirlpool
• Transport the patient from his hospital room to the physical therapy department
• Follow behind a therapist walking with a patient with the wheelchair as a precaution

Examples of procedures in the Policy & Procedures Manual include all of the following except:

• The statement saying that the whirlpool must be cleaned after each patient
• The detailed descriptions of how to clean the whirlpool
• Fire procedure descriptions
• Descriptions of how to dispose of hazardous waste

• The statement saying that the whirlpool must be cleaned after each patient

The highest policy-making body of the APTA is:

A.Special Interest Group

B.Political Action Committee

C.House of Delegates

D.All of the above

C. House of Delegates

A type of budget that includes utilities, employees' salaries and benefits, supplies, housekeeping, and maintenance is considered:

• Operating expense budget
• Capital expense budget
• Accounts receivable budget
• Accounts payable budget

• Operating expense budget

• 3000BC: China?

therapeutic ex., massage, hydrotherapy

• 1000BC: China-Cong Fu: exercise to relief PAIN

Cong Fu: exercise to relief PAIN

• Per Henrik Ling (poet/educator/fencing master):

Swedish Gymnastics and Swedish Massage

›1864: Gustav Zander–exercise machines

›assist and resist exercises

›1890: Nikola Tesla–diathermy

diathermy

›Proprioceptive facilitation:

• ›Knott and Dorothy Voss

PNF

›Proprioceptive Neuromuscular Facilitation

›Lovett (Harvard): importance of polio early muscle training

›

polio early muscle training

Mary McMillan-

• 1918 sworn as Member US Army Corps.
• 1919 Work at ›Walter Reed General Hospital
• 1918 trained Reconstruction Aides–Reed College, Portland, Oregon
• AWPT President–1921–1923
• P.T. Review: 1921
• AWPT Constitution and Bylaws: 1921

Mckenzie

Stretch the opposite way (extension)

Williams

Stretch regular way (flexion)

Physical therapy was call?

Reconstruction Aid

1.Merguerite Sanderson-

• 1917-22 Supervisor of Reconstruction Aides

creation: 1967

APTA–PTA

American Physical Therapy Association

Physical Therapy Association

• What Two city PTA programs was first created in 1969?

• Miami Dade CC in Miami;
• St. Mary’s Campus of the College of St. Catherine in Minneapolis

Which World War generated more demand for Physical Aid?

WW2

What year was (CAPTE) created?

1977 Commission on Accreditation in Physical Therapy Education

• PT Specialty sections was created in?

1978

• Federation of State Boards of Physical Therapy (FSBPT) was created in?:

1986

(ABPTS)

American Board of Physical Therapy Specialties

Vision Statement for the Physical Therapy Profession

Transforming society by optimizing movement to improve the human experience.

• Direct Access: 1988

1988 Patient can receive care for up to 21 days

House of Delegates?

Components

• 52 chapters
• 18 sections
• 2 assemblies (PTA Caucus and Student Assembly)

APTA’s Benefits for Student Members

• ›Career guidance
• ›Member discounts
• ›Mentoring program
• ›Scholarship and internship
• ›Legislative representation
• ›E-newsletter

Group discussion (6)

›HOD (House of delegates)

›BOD (Board of director)

›CAPTE

›ABPTS

›FSBPT

›PT-PAC

APTA’s Goals

• Practitioners:

• choice, persons with conditions that affect movement and function

APTA’s Goals

• Providers:

• Fitness, health promotion, wellness,risk reduction programs, enhance quality of life persons across life span PTs/PTAs

APTA’s Goals

• Committed:

• Meeting health needs patients/clients, society through ethical behavior, continued competence, collegial relationships other healthcare practitioners, advocacy profession

APTA’s Board of Directors and Headquarters

›Six officers

• President
• Vice President
• Secretary
• Treasurer
• Speaker of the House of Delegates
• Vice Speaker of the House of Delegates

PTA:

• technically educated healthcare provider
• individual works under direction and supervision of PT

Supervision of PTA

• Dependent clinical site jurisdiction

PT:

conducts physical therapy practice

General supervision ie In Home PT?

PT available telecommunication

Direct personal supervision?

PT available on-site at all times

PTA Duties (as per the APTA)

Performs selected physical therapy interventions under the direction and at least general supervision of PT–dependent on the jurisdiction of clinical site

who can make modification to patient intervention?

Makes modifications to selected interventions to progress the patient/client, as directed by the PT, or to ensure patient/client safety and comfort

Upon PTA’s request patient’s re-examination

When POC change needed

Prior planned discharge

In response: change patient’s medical status

Once/month or higher frequency–patient’s needs

Supervisory visits by the PT

performs initial examination/evaluation, establishes POC and treatment plan

PT

initial examination/evaluation; PTA takes notes and gathers data as requested by PT

PTA can helps PT:

Evaluation is when

PT interprets the results of the data collected by the PTA from the initial examination of a patient.

who performs patient’s interventions?

• PT
• PTA performs selected patient’s interventions as directed by PT
• PTA performs data collection during interventions;
• PTA records patient’s progress or lack of progress;
• PTA may ask PT for re-examination

The PT is the only person that can?

performs re-examination and establishes new treatment plan

When a patient is done with treatment who can discharge them?

PT performs discharge examination and evaluation of patient

1.Intra-disciplinary :

members work together within the same discipline–PT and PTA in home health care

2.Inter-disciplinary :

members work together within all disciplines–SNF team: PT, PTA, SLP, OT, COTA, MD, RN, SW, LPN

3.Multi-disciplinary :

members work separately and independently in different disciplines, different medical specialties

PT and PTA

OTR/L and COTA

SLP

RN,

LPN,

CNA

SW

ATC

PT and PTA

OTR/L and COTA

SLP

RN,

LPN,

CNA

SW

ATC

Discontinue

Discontinuing interventions due to…

• patient/client’s inability to benefit from the therapy or progress
• complications/finances

• ADL- Activities of Daily Living

Bathing, eating, grooming

IADL- Instrumental Activities of Daily Living

Shopping, home maintenance, yard work

• Departmental meetings:

Staff/departmental team:

PT, PTA, OTR/L, COTA, SLP, SW, RN (Everybody)

• Departmental meetings

Supervisory:

between PT and PTA

• Departmental meetings

Strategic planning:

Dept. goals

• Budgets

Operating expense:

salaries, benefits

• Budgets

Capital expense:

equipment > $300

• Budgets

Accounts receivable:

Medicare funds/ 80%

• Budgets

Accounts payable:

money for services or equipment

• Costs

Direct:

salaries, equipment

• Costs

Indirect:

housekeeping, utilities

• Costs

Variable:

electricity

• Costs

Fixed

Rent

Q&A

monitors quality and appropriateness of care–resolves identified problems

QA

• Utilization Review: evaluates necessity, effectiveness, efficiency

Risk Management:

implements quality assurance and defends against legal liability threats (safety education, identify potential employee injuries, report all incidents)

—Traditional definition of —Health

—

• Free/absent from disease
• Emphasis on treating or curing disease

Disablement

Difference between Nagi and ICF framework

• —The consequences of diseases as they pertain to the
• relationship between body structures ,
• ability to carry out tasks ,
• ability to function within society.

—T raditionally

• —Measured impairments or deviations of structures or functions
• —Anatomical
• —Physiological
• —Mental
• —Psychological

—Contemporary

—Examine how patient functions in his environment.

—Observation of patient performing functional task

—Patient self-report questionnaire

The Nagi Framework

• —Developed by Saad Nagi
• —Developed in 1960’s
• —Adopted by APTA for framework to utilize in the Guide to Physical Therapist Practice

Pathology

—The interruption or interference with normal process and simultaneous body efforts to heal itself, or regain a normal state.

The Nagi Framework Pathology is Often referred to as the disease itself?

True or False

True

The Nagi Framework Pathology happens where?

—Occurs at the following levels:

• —Cellular
• —Tissue
• —Organ

—Management focused on reducing active pathology

Impairment

—Is a loss or abnormality of an anatomical, physiological, mental, or emotional nature

Impairment is also a —deviations in normal anatomy and/or physiology of daily life, example

—

• Physiological
• —Mental
• —Emotional
• —Limited range of motion
• —Muscle weakness
• —Impaired balance
• —Decreased concentration

Functional Limitation

—An abnormality or limitation in an individual’s ability to carry out a meaningful action, task or activity.

Nagi model: Functional Limitation:

Activities of daily living (ADL)

—Basic activities

• ——Moving in and out of bed
• —Ambulating
• —Rising from a chair

Nagi model: Functional Limitation

Instrumental activities of daily living (IADL)

—

• —Community ambulation
• —Going to the grocery store

Disabilities

—The inability or limitation in performing socially defined roles and/or tasks that would normally be expected of an individual within a given culture and/or environment

Disability

Roles or tasks that have been socially defined as normal for a given population is?

• —Self-care
• —Home management
• —Work
• —Community
• —Leisure

Factors that influence an individual’s perception of his/her degree of disability?

• ——The individual’s situation and his or her reactions to the situation
• —The reactions of others:
• —Family
• —Friends
• —Associates
• —Co-workers
• —Environmental barriers that are present

International Classification of Function (ICF)

—Originally known as: International Classification of Impairments, Disabilities, and Handicaps (ICIDH)

—Developed by the World Health Organization (WHO )

—Purpose:

—To provide uniform, standard language for describing health and health-related states

—Accounts for facilitators and barriers to function

—E.g.. Ramps & handrails

—Integrates the biomedical, psychological and social aspects of disease.

International Classification of Function (ICF)

International Classification of Function (ICF)

Describes various aspects of health as they relate to:

—

• —the body
• —the individual
• —society

International Classification of Function (ICF)

Described in terms of function and disability

—

—What the individual CAN do

—Function

—Positive aspects of health

—

What the individual CANNOT do

—Disability

—Negative aspects of health

—These two systems are meant to complement each other

— ICF – International Classification of Function

— ICD – International Classification of Diseases

—Classification system for medical diagnoses and diseases

—ICD-10

Disablement models provide framework for understanding relationships between

• —Disease
• —Impairments
• —Functional Limitations
• —Disability

Comparison of ICF and Nagi model’s

—“Both models provide a framework for examining the relationship between disease, impairments, functional limitations and disability”

—

—Both identify how the disease impacts the individual’s daily life activities

—

—In the ICF enablement model there is a focus on what can the person do instead of what they cannot do (hence using the words enablement and disablement)

Comparison of Nagi and ICF cont .

—In the Nagi model of disablement it is understood that sometimes functional limitations do not always cause disabilities depending on what the person needs to accomplish or their environment but ICF enablement does includes it in their model

—

—ICF integrates both personal factors and environmental factors while the Nagi disablement model focuses primarily on factors associated with the consequences of the disease

—

—ICF by integrating personal and environmental factors provides a structure where individual differences in health, function and disability are incorporated

Documentation

—Provides:

—Legal record of care

—Facilitates communication among health care providers

—Serves as a source of information for clinical research

Documentation for Reimbursement

• —Third party payment is linked to documentation demonstration of the need for PT services.
• —Became a requirement for reimbursement as early as 1966 with Medicare & Medicaid.
• —Continuation of benefits is largely based on how well documentation demonstrates
• —Patient improvement
• —Need for ongoing services

Documentation as Ethical Duty

—APTA’s Standards of Ethical Conduct for the Physical Therapist Assistant

“Physical therapist assistants shall ensure that documentation for their interventions accurately reflects the nature and extent of services provided.”

Initial examination

—

—Performed by the PT

—Includes the following information:

SUBJECTED

OBJECTIVE

Subjective (what you here)

• ——What the patient says
• —Medical condition
• —Patient’s living situation
• —Chief complaint
• —Goals for physical therapy

Objective (test you do with the patient)

Results of tests and/or measurements

—

• —ROM
• —Strength
• —Sensation
• —Girth
• —Functional status

the Initial examination is used as a

—

—As a baseline to determine progress toward goals

Record Patient Care:

Direct

• Modalities
• —Physical agents
• —Ice
• —Heat
• —Massage
• —Stretching exercises
• —Strengthening exercises
• —Gait training
• —Transfer training

Record Patient Care:

Indirect

• —Patient education
• —Phone calls
• —Collaboration with other providers
• —Conversations with patients

Skilled Care

—A type of health care given when a patient needs management, observation, or evaluation by trained nurses or rehabilitation staff; also includes are that required the unique judgment and skill of a trained individual for both safety and effectiveness.

In order for an intervention to be skilled

—The intervention requires the unique judgment and/or skill of a trained individual for:

• —Safety
• —Effectiveness
• —Specific to the patient’s condition.

Maintenance Therapy:

—Services that are not skilled.

• —Can be provided by a non-licensed individual
• —Family member
• —Caregiver
• —Patient – through HEP
• —Not reimbursed by Medicare of many other third-party payers

In which of the following elements of the patient/client management model does the PTA have documentation responsibilities? (Indicate all that apply)

Evaluation

Diagnosis

Prognosis

Intervention

Re-evaluation

Intervention

Re-evaluation

Question 3

For a patient/client to have direct access to physical therapy care which of the following must occur?

The insurance company must be willing to pay for it.

The intervention must not be provided by a PTA.

The PT must have graduated with a doctoral degree (have a DPT).

The state practice act must allow for it.

• The state practice act must allow for it.

Question 4

The most common orthopedic condition of elderly adults in the U.S. is

Lateral epicondylitis

Spondylolisthesis

DeQuervaine’s syndrome

Hip fracture

• Hip fracture

Question 5

Aquatic therapy is a form of hydrotherapy.

True

False

• True

Question 6

In what section of an treatment note would you make the following entry? “Pt. c/o weakness in (R) elbow.”

S

O

A

P

S-Subjective

Question 7

Scoliosis curvatures of more than 40 degrees need the Milwaukee orthosis and functional electrical stimulation (FES) to the muscles on the convex side of the curve.

True

False

• False

Computer-based documentation packages utilize:

Check boxes and drop-down menus

Free-text boxes

Templates and fill-in forms

All of the above

All the above

Question 9

In which section of the SOAP note would you document patient-related instructions that were given?

Pr

S

O

A

P

Pr

Question 10

The Numerical Rating System (NRS) consists of a 10 cm unmarked horizontal line and is used for pain description.

True

False

False

Question 11

In what section of an interim note would you make the following entry? “PROM: (R) hip flexion 0° to 115°.”

S

O

A

P

O-objective

Question 12

Select the items below that represent pathophysiology

• Down syndrome
• Quadripceps weakness
• Inability to take a shower
• Wheelchair bound
• End-stage renal failure

• End-stage renal failure
• Down syndrome

AAROM exercises can be done using all of the following except:

• Continuous Passive Motion (CPM) device
• Patient holding on to a wand with both hands and using the unaffected arm to assist with raising the injured arm.
• Manual assistance from PT/PTA
• Overhead pulleys using the patient's own arms.

• Continuous Passive Motion (CPM) device

Question 14

• Multiple Answer: When taking a telephone referral, the PTA needs to document:
• The date, time, and name of the caller
• The name of the health care provider who referred the patient
• The name of the patient and all other details in regard to the referral
• The name of the PT responsible for the referred patient and the name of the PTA who took the referral

• The date, time, and name of the caller
• The name of the health care provider who referred the patient
• The name of the patient and all other details in regard to the referral
• The name of the PT responsible for the referred patient and the name of the PTA who took the referral

Question 15

Select the items below that represent impairments

• Pain in the left shoulder
• Inability to take a cup out of a cabinet
• Inability to participate in a marathon
• End-stage renal failure

• Pain in the left shoulder
• End-stage renal failure

Question 16

All of the following are isotonic exercises except:

• PNF exercises
• TheraBand exercises
• Quadriceps sets
• Progressive Resistive Exercises (PREs)
• All of the above

• Quadriceps sets

Question 17

During isometric exercises, the patient must be closely supervised for the potential of Valsalva maneuver.

True

False

• True

Question 18

A patient's history may include all of the following except:

• Personal information and medical diagnosis
• Mechanism of injury and symptoms of the present illness
• Manual Muscle Testing (MMT) and gait observation
• All of the above

• Manual Muscle Testing (MMT) and gait observation

Question 19

The Plan of Care (POC) in the initial examination and evaluation may include:

• Short term goals (STGs) and Long term goals (LTGs)
• treatment intervensions
• patient's rehab potential (prognosis)
• All of the above

• Short term goals (STGs) and Long term goals (LTGs)

Question 20

The SOAP format data can be utilized for all of the following except:

• PT's initial evaluation
• PTA's initial evaluation
• PTA's daily/weekly progress notes
• All of the above

• PTA's initial evaluation

Question 21

Which of the following pieces of information would be best obtained from the patient’s medical history?

• Number of stairs to enter the home
• The patient’s cognitive status
• The patient’s pain rating
• The type of surgery the patient underwent

• The type of surgery the patient underwent

Question 22

The Objecitve data in the "O" section of the daily or weekly SOAP note contains all of the following information except:

• Girth measurements
• PROM measurments
• Patient's progress toward STGs and LTGs
• Strength MMT measurments

• Patient's progress toward STGs and LTGs

Question 23

Which of the following types of information frequently is documented in column or table form?

• Gait deviations
• Goniometric AROM measurements
• Pain rating related to exercises
• Short-term goals

• Goniometric AROM measurements

Question 24

Select the items below that represent disability

• Low back pain
• Abdominal weakness
• Inability to participate in work-related activities
• Inability to play with grandchildren
• Stroke

• Inability to participate in work-related activities
• Inability to play with grandchildren

estion 25

In what section of an initial evaluative note would you find the following entry? “Progressive remitting type MS with balance and coordination deficits.”

Pr

S

O

A

P

• Pr

Question 26

In what section of an interim note would you make the following entry? “Pt. c/o weakness in (L) knee.”

S

O

A

P

S-Subjective

Question 27

Which of the following pieces of information would be best obtained from the patient’s medical history?

• Number of stairs to enter the home
• The patient’s cognitive status
• The patient’s pain rating
• The type of surgery the patient underwent

• The type of surgery the patient underwent

Question 28

Which of the following components of the examination provides the physical therapist with information about the patient’s past health, mechanism of injury, and prior injuries.

• Prognosis
• History
• Systems review
• Tests and measures

• History

Question 29

Select the items below that represent functional limitations

• Diabetes
• Deltoid weakness
• Inability to brush hair
• Difficulty walking
• Stroke

• Inability to brush hair
• Difficulty walking

Question 30

PROM exercises can increase a patient's muscular strength.

True

False

• True

Question 31

Function can be integrated into which of the following documentation formats?

• Narrative
• Problem-oriented medical records
• SOAP notes
• Any of the above

• Any of the above

• Cardio

• HEART
• CAD-CORONARY ARTERY DIASEASE
• CHF- CONGESTIVE HEART FAILURE

• PULMONARY

• LUNGS
• COPD- CHRONIC OBSTRUCTIVE PULMONARY DISEASES
• ASTHMA

SOME PT AND PTA ROLE(S)

• MONITOR VITALS SIGNS
• HEART RATE- HR (PULSE)
• BLOOD PRESSURE- mmHg
• RESPIRATION RATE- RR
• TEMPERATURE- degrees

• MYOCARDIAL INFARCTION (MI)

OTHER SYMPTOMS:

• DYSPNEA OR SHORTNESS OF BREATH, FATIGUE, GENERALIZED WEAKNESS, EDEMA

DIAGNOSTIC TESTS:

• ELECTROCARDIOGRAM-ECG
• CONDUCTION, ISCHEMIA, INCREASED SIZE OF HEART

SECRETION REMOVAL TECHNIQUE

• SECRETIONS INTERFERE WITH
• VENTILATION
• DIFFUSION OF O2 AND CARBON DIOXIDE
• INDIVIDUALIZED PROGRAM
• POSTURAL DRAINAGE
• MASSAGE TECHNIQUES-DEMO
• PERCUSSION
• VIBRATION
• AIRWAY CLEARANCE

CAD-CORONARY ARTERY DISEASE

• ANGINA PECTORIS
• MI- MYOCARDIAL INFARCTION

Chronic obstructive pulmonary disease (COPD)

• EMPHYSEMA
• CHRONIC BRONCHITIS

Documentation

• Includes initial eval, POC, interim treatment notes, progress notes, discharge summary
• Legal document
• Who, what, when

• Timely
• Thorough, relevant, accurate
• Clear and concise
• Consistent
• Use objective language
• Legibly
• Black or blue permanent ink
• Use medical terminology

Documentation

Addendum" immediate

• Document "late entry" after original, after the date of tx

Objective Data should fall into 2 categories:

1.Physical therapy intervention provided

2.Information that demonstrates the pt’s response to the physical therapy intervention provided

• Subheadings

• Subheadings can be used to organize the (O) objective

Structure/Organization of O: con’t

• Often information in the objective section is best communicated in list column, or table format
• Objective data can be put in a chart

ROM Strength

• R LE Hip flex 100 3+/5

ext 10 4/5

IR 20 3/5

ER 15 5/5

Describing function

• Can show improvement by describing the pt’s function
• Make sure you are documenting all factors involved (assistance, time takes, cueing, feedback etc)
• When documenting gait, document deviations, assistance, distance, pattern, assistive devices, cueing and facilitation
• When documenting a transfer, document assistance, starting point to ending point and how the patient performed the task (did not WB L etc)

Therapeutic Exercise

• Make sure you document:
• Specific activities/exercises performed
• Equipment used
• Patient position (if not clear from exercise)
• Reps/duration

Wound Management

• Make sure you document:
• Application/removal of dressings or agents
• Type and amount of dressing used
• Precautions for dressing removal

Muscle Strength

• Make sure you document:
• Range (3/5 not just 3)
• What is being measured:
• Muscle group (hip flexors)
• Specific muscles (glut max)
• Arrange logically
• Group anatomic location together
• Use tables or columns to show bil measurements/ IE
• Deviations from standard positions

Orthotics

• Specify device being used (AFO, HKAFO)
• Discuss pt’s/family’s ability to care for the device
• Discuss pt’s ability to don/doff device as appropriate
• Discuss safety risks associated with the use of the device

Gait/Balance

• Indicate activity (ambulation or w/c mobil)
• Indicate AD, orthotics
• Indicate assistance given
• Type of surface traveled upon (grass, level surface, stairs)
• Distance traveled/amount of time
• Number of people needed
• Cues given
• Gait pattern/deviations
• Weight bearing status

Common Mistakes

• Don’t report what you did. Report how the patient did. How did the pt respond to treatment
• Be concise and organized