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 physical therapist working in an outpatient clinic receives a subpoena for a patient's medical records. The therapist should FIRST:
Answer: Consult the facility's legal counsel before releasing any records
Upon receiving a subpoena, the therapist should immediately consult legal counsel to determine the appropriate response and ensure compliance with both legal and privacy requirements.
The International Classification of Functioning, Disability and Health (ICF) model is MOST useful in physical therapy documentation for:
Answer: Providing a comprehensive framework that links health conditions to activity and participation
The ICF model provides a biopsychosocial framework that connects body function and structure with activity limitations and participation restrictions, giving documentation a holistic view.
A physical therapist writes a goal: 'Improve patient's balance.' This goal is considered inadequate because it lacks:
Answer: Specificity, measurability, and a time frame
Effective goals must be specific, measurable, achievable, relevant, and time-bound (SMART); 'improve balance' lacks measurable criteria and a target date.
During a team conference, a physician interrupts the physical therapist mid-sentence while presenting a patient case. The MOST professional response is to:
Answer: Calmly and assertively request an opportunity to finish the clinical point
Assertive, professional communication in interdisciplinary settings includes politely but firmly ensuring all relevant clinical information is heard.
A physical therapist is treating a patient who discloses they are experiencing domestic abuse at home. The therapist's PRIMARY obligation is to:
Answer: Follow mandatory reporting laws and facility protocols for disclosure of abuse
Physical therapists are mandated reporters in most jurisdictions and must follow applicable laws and facility protocols when a patient discloses abuse.
Which of the following BEST describes the concept of 'minimum necessary' under HIPAA?
Answer: Releasing the smallest possible amount of PHI needed to accomplish the intended purpose
The 'minimum necessary' standard requires that only the amount of protected health information needed for a specific purpose be used or disclosed.
A physical therapist completes an evaluation but is unable to establish a physical therapy diagnosis due to insufficient findings. The MOST appropriate action is to:
Answer: Document findings thoroughly, indicate that further assessment is needed, and seek consultation if appropriate
When insufficient data exists to establish a PT diagnosis, thorough documentation of findings and identification of next steps (including consultation) reflects sound clinical and documentation practice.