PCE Communication and Documentation 2

Question 1

A patient refuses to continue with a prescribed home exercise program. What is the MOST appropriate initial response by the physical therapist?

Accepted Answer

Explore the patient's reasons for refusal and address barriers collaboratively

Answer

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?

Accepted Answer

Subjective

Answer

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:

Accepted Answer

Measurable changes in function relative to goals

Answer

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:

Accepted Answer

Provide the records since a minor's parent generally has access rights

Answer

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?

Accepted Answer

To quantify patient status and track change over time

Answer

Outcome measures provide standardized, quantifiable data that allow comparison of patient status at different time points to demonstrate progress.

(PCE) Physiotherapy Competency Exam Practice Test

(PCE) Physiotherapy Competency Exam Practice Test

PCE Communication and Documentation 2