PC Patient Assessment & Documentation 3 — Questions and Answers
Question 1: Which grading system is used to document the severity of onychomycosis in a podiatric medical record?
- Onychomycosis Severity Index (OSI) (Correct answer)
- Wagner Classification
- PEDIS System
- Meggitt Grading
Correct answer: Onychomycosis Severity Index (OSI)
The Onychomycosis Severity Index (OSI) scores disease severity based on area of involvement, proximity to matrix, and presence of dermatophytoma or subungual hyperkeratosis.
Question 2: A podiatrist documents 'erythema extending 2 cm beyond wound margin with warmth and purulent discharge.' This describes which stage of wound condition?
- Infected wound (Correct answer)
- Granulating wound
- Epithelializing wound
- Sloughing wound
Correct answer: Infected wound
Purulent discharge, perilesional erythema, and warmth are classic signs of wound infection requiring documentation and treatment.
Question 3: When obtaining a podiatric history, which family history factor is most relevant to document for a patient presenting with hallux valgus?
- First-degree relatives with bunion deformity (Correct answer)
- Family history of rheumatoid arthritis only
- Parental history of flat feet only
- Maternal history of osteoporosis
Correct answer: First-degree relatives with bunion deformity
Hallux valgus has a strong hereditary component, making a family history of bunion deformity the most directly relevant factor to document.
Question 4: In documenting a patient's range of motion at the first metatarsophalangeal joint, what is the normal range of dorsiflexion?
- 65–75 degrees (Correct answer)
- 20–30 degrees
- 45–55 degrees
- 90–100 degrees
Correct answer: 65–75 degrees
Normal first MTP dorsiflexion is 65–75 degrees; values below 65 degrees may indicate hallux limitus.
Question 5: Which documentation element is MANDATORY when a podiatrist performs a podiatric history and physical on a Medicare patient?
- Time of service and medical necessity statement (Correct answer)
- Patient's employment status
- Insurance policy expiration date
- Number of prior podiatric visits
Correct answer: Time of service and medical necessity statement
Medicare requires documentation of time of service and a clear statement of medical necessity to justify covered podiatric services.
Question 6: A podiatrist notes 'subungual hematoma involving approximately 25% of the nail plate.' Which documentation practice best supports this entry?
- Drawing a diagram of the nail with shading to indicate the affected area (Correct answer)
- Photographing only after treatment
- Relying solely on the written description
- Using a grading scale not referenced in the record
Correct answer: Drawing a diagram of the nail with shading to indicate the affected area
Anatomical diagrams supplement written descriptions and provide a clear visual record of nail pathology extent and location.
Question 7: What is the purpose of documenting the '5 P's' (Pain, Pallor, Pulselessness, Paresthesia, Paralysis) in a lower extremity assessment?
- To identify signs of acute compartment syndrome or arterial occlusion (Correct answer)
- To classify peripheral neuropathy severity
- To document diabetic foot risk category
- To assess venous insufficiency staging
Correct answer: To identify signs of acute compartment syndrome or arterial occlusion
The 5 P's are classic signs of acute limb ischemia or compartment syndrome, requiring urgent intervention when present.
PC Patient Assessment & Documentation 3
Which grading system is used to document the severity of onychomycosis in a podiatric medical record?