Documentation questions

INSTRUCTIONS:

READ CHAPTERS 3 and 4!! 

• Must be typed using Microsoft Word and in your OWN words.
• Be careful of spelling, grammar and sentence structure. MUST proofread. 
• DO NOT rewrite questions, keep answers SHORT, clear and concise.

 Chapter 3 

 You need to define ALL key terms that appear at the top of this Chapter

1.List reasons for documenting.

2. Review the Standards of Ethical Conduct for the Physical Therapist Assistant (http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/StandardsEthicalConductPTA.pdf) and identify your professional obligation(s) that pertain to documentation.

3. What are some examples of subjective and objective data that can be gathered by a physical therapist assistant?

4. How can a clinician integrate the clinical decision-making process in his or her documentation?

5. Provide some examples of how a physical therapist assistant can assist in showing clinical decision making in the medical record.

6. What are the criteria for determining whether a treatment or intervention is reasonable and necessary?

8. What is the difference between skilled care and maintenance therapy? Provide an example of each.

9. What is the role of the physical therapist assistant in determining medical necessity?

10. How does the patient’s rehabilitation potential influence his or her need for medically necessary skilled care?

Chapter 4.

 You need to define ALL key terms that appear at the top of this Chapter

1-List 4 documentation formats used in physical therapy.

2. Describe the similarities and differences between narrative notes, POMRs, SOAP notes, and FOR.

3. Describe the advantages and disadvantages of narrative notes, POMRs, SOAP notes, and FOR.

4. What type of information is found in the S, O, A, and P portions of a SOAP note?

5. When using SOAP and POMR formats, where should you place information provided by the patient’s family?

6. Describe how the FOR and SOAP format can be used together.

7. What are the positive and negative aspects of using forms and templates?

8. Why is it important to learn the different documentation formats?