Communication and Documentation Flashcards
7 cards from real PCE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Communication and Documentation flashcards as text
A patient refuses to continue with a prescribed home exercise program. What is the MOST appropriate initial response by the physical therapist?
Answer: Explore the patient's reasons for refusal and address barriers collaboratively
Exploring the patient's concerns and collaboratively addressing barriers to adherence is the most patient-centered and therapeutically appropriate first step.
Which SOAP note component would include a patient's report of pain level as 6/10 with ambulation?
Answer: Subjective
The Subjective section records information reported by the patient, including self-reported pain ratings.
When documenting a patient's functional progress, the physical therapist should primarily focus on:
Answer: Measurable changes in function relative to goals
Progress notes should document measurable, objective changes in patient function compared to established goals to justify continued treatment.
A physical therapist is treating a 16-year-old patient. The patient's parent requests a copy of the session notes. Under HIPAA, the therapist should:
Answer: Provide the records since a minor's parent generally has access rights
Under HIPAA, parents or legal guardians of unemancipated minors generally have the right to access their child's protected health information.
Which of the following BEST describes the purpose of an outcome measure in physical therapy documentation?
Answer: To quantify patient status and track change over time
Outcome measures provide standardized, quantifiable data that allow comparison of patient status at different time points to demonstrate progress.
A physical therapist needs to communicate a patient's transfer-of-care information to a home health agency. The MOST appropriate method is:
Answer: A written discharge summary including functional status, goals, and home program
A comprehensive written discharge summary ensures continuity of care by providing the receiving provider with all clinically relevant information.
In a physical therapy evaluation note, the assessment section should contain:
Answer: Clinical interpretation of findings and a problem list
The Assessment section contains the therapist's clinical reasoning, interpretation of objective findings, and identification of patient problems.