Exam 1: Introduction to Documentation

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What state became the first state to allow direct access?

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When was the first academic program developed for the PTA?

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During which time period did documentation change, requiring more specific information?

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Which taxonomy can be defined as the loss or abnormality of a physiological, psychological, or anatomical structure or function?

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Direct access allows PTs to practice with autonomy because it is understood that PTs recognize their legal responsibilities.What is this legal responsibility called?

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What is the website for the American Physical Therapy Association (APTA)?

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What is the focus of outcomes in patient care related to PT and PTA documentation?

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2-8-98: Pt. feeling better today. Pt. was seen for a 30 minute therapy visit. \quad S: Mom told PTA that her son is cranky and stiff. \quad O: Worked on sitting and rolling. \quad A: Pt. able to sit by himself for short time periods. \quad P: Continue PT sessions. -In the SOAP note example provided in Figure , why was the objective section incorrect?

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Which two goals must physical therapy meet for the PT to receive reimbursement for services?

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Why is documentation necessary in patient care?

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What is the definition of documentation?

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Documentation must meet today's standards for reimbursement and provides the basis for research.What two standards must be met for reimbursement to be successful?

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To provide high-quality medical care, the PT and PTA must demonstrate one exceptional skill.What is that one skill?

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What two events changed treatment and documentation responsibilities for the PT and PTA?

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2-8-98: Pt. feeling better today. Pt. was seen for a 30 minute therapy visit. \quad S: Mom told PTA that her son is cranky and stiff. \quad O: Worked on sitting and rolling. \quad A: Pt. able to sit by himself for short time periods. \quad P: Continue PT sessions. -In the SOAP note example provided in Figure , why is the assessment section incorrect?

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What type of access allows a patient to see a PT without a physician's referral?

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Documentation classification has evolved over many years.Which documentation classification provides a definitive summary of an active pathology with the relationship to the resulting impairment?

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What is the name of the accrediting agency for hospitals?

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What is the name of the accrediting agency for rehabilitation facilities?

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What specific piece of legislation was responsible for changing the documentation process?

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