PCE Communication and Documentation 2 — Questions and Answers
Question 1: A patient refuses to continue with a prescribed home exercise program. What is the MOST appropriate initial response by the physical therapist?
- Document the refusal and notify the referring physician immediately
- Explore the patient's reasons for refusal and address barriers collaboratively (Correct answer)
- Discharge the patient for non-compliance
- Reduce the frequency of exercises without discussing it with the patient
Correct 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.
Question 2: Which SOAP note component would include a patient's report of pain level as 6/10 with ambulation?
- Assessment
- Plan
- Subjective (Correct answer)
- Objective
Correct answer: Subjective
The Subjective section records information reported by the patient, including self-reported pain ratings.
Question 3: When documenting a patient's functional progress, the physical therapist should primarily focus on:
- The specific exercises performed during the session
- Measurable changes in function relative to goals (Correct answer)
- The therapist's clinical impressions without data
- Insurance billing codes used
Correct 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.
Question 4: 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:
- Refuse the request as the patient is old enough to consent independently
- Provide the records since a minor's parent generally has access rights (Correct answer)
- Only provide a summary, not the full notes
- Require a court order before releasing any information
Correct 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.
Question 5: Which of the following BEST describes the purpose of an outcome measure in physical therapy documentation?
- To record the therapist's treatment techniques
- To quantify patient status and track change over time (Correct answer)
- To fulfill billing requirements only
- To describe the patient's diagnosis in medical terminology
Correct 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.
Question 6: A physical therapist needs to communicate a patient's transfer-of-care information to a home health agency. The MOST appropriate method is:
- A verbal summary given to the receiving therapist over the phone without documentation
- A written discharge summary including functional status, goals, and home program (Correct answer)
- A brief email with only the patient's name and diagnosis
- Instructing the patient to communicate their own status to the new provider
Correct 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.
Question 7: In a physical therapy evaluation note, the assessment section should contain:
- Raw goniometric measurements and MMT grades
- The frequency and duration of planned treatment sessions
- Clinical interpretation of findings and a problem list (Correct answer)
- The patient's chief complaint in their own words
Correct 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.
PCE Communication and Documentation 2
A patient refuses to continue with a prescribed home exercise program.
What is the MOST appropriate initial response by the physical therapist?