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
Which of the following BEST demonstrates patient-centered communication during a physical therapy session?
Answer: Asking open-ended questions to understand the patient's goals and concerns
Open-ended questions invite patients to share their perspectives and goals, forming the foundation of patient-centered communication.
A late entry in a medical record should be documented by:
Answer: Writing 'late entry,' the current date, and signing it
Late entries must be clearly labeled as such with the current date and time to maintain the integrity and accuracy of the medical record.
A physical therapist is asked by a patient's employer whether the patient is 'ready to return to work.' Without the patient's written consent, the therapist should:
Answer: Decline to share any information without the patient's written authorization
HIPAA requires written patient authorization before releasing protected health information to an employer, regardless of the relevance of the information.
In motivational interviewing, the 'rolling with resistance' technique involves:
Answer: Avoiding argument and reflecting the patient's ambivalence back without judgment
Rolling with resistance means acknowledging and reflecting the patient's resistance without direct confrontation, keeping them engaged in the conversation.
Which documentation format is MOST appropriate for tracking a patient's daily progress in an inpatient rehabilitation setting?
Answer: Daily treatment notes or flow sheets documenting each session's findings
Daily treatment notes or flow sheets provide the continuous record of patient response and progress required in inpatient rehabilitation settings.
A physical therapist notices a documentation error in a previously signed note. The CORRECT way to correct this error is to:
Answer: Draw a single line through the error, write the correction, date it, and initial it
The correct method for correcting a paper record error is a single line through the incorrect entry, the correction, current date, and the clinician's initials.
When explaining a complex rehabilitation plan to a patient with low health literacy, the therapist should PRIMARILY:
Answer: Use plain language, teach-back method, and written materials at an appropriate reading level
Plain language combined with the teach-back method and appropriately leveled materials are evidence-based strategies for communicating with patients with low health literacy.