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 with limited English proficiency arrives for their first PT appointment without an interpreter. The BEST course of action is to:
Answer: Arrange for a qualified medical interpreter before proceeding
Federal law and ethical practice require using a qualified medical interpreter to ensure accurate communication and informed consent.
Which of the following is an example of an impairment-level goal in a physical therapy plan of care?
Answer: Patient will increase quadriceps strength from 3+/5 to 4+/5 in 3 weeks
Impairment-level goals address body structure and function deficits, such as muscle strength measured by MMT grades.
A physical therapist suspects a colleague is documenting treatments that were not actually performed. The MOST appropriate action is to:
Answer: Report the concern through the appropriate institutional or regulatory channel
Fraudulent documentation is a serious ethical and legal violation that must be reported through proper institutional channels or to the relevant licensing board.
When writing a physical therapy discharge summary, which element is MOST critical to include?
Answer: The patient's final functional status compared to initial status and goals
The discharge summary must compare initial and final functional status against established goals to justify the episode of care and guide future management.
A physical therapist is working in a school setting and wants to share a student's therapy progress with the classroom teacher. Which law primarily governs this information sharing?
Answer: FERPA
FERPA (Family Educational Rights and Privacy Act) governs educational records in school settings, taking precedence over HIPAA for student health information in that context.
The term 'active listening' in patient communication BEST refers to:
Answer: Fully concentrating, understanding, and responding to the patient's verbal and non-verbal messages
Active listening involves full engagement with both the content and emotional context of a patient's communication, including non-verbal cues.
A physical therapist documents 'patient tolerated treatment well' after a session. This statement is BEST described as:
Answer: Subjective and non-specific
'Patient tolerated treatment well' is vague, non-measurable, and does not describe specific patient responses, making it a poor documentation practice.