PCE Communication and Documentation 3 — Questions and Answers
Question 1: A patient with limited English proficiency arrives for their first PT appointment without an interpreter. The BEST course of action is to:
- Proceed with the evaluation using gestures and simple words
- Use the patient's adult family member as an interpreter
- Arrange for a qualified medical interpreter before proceeding (Correct answer)
- Reschedule the appointment until the patient can bring someone who speaks English
Correct 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.
Question 2: Which of the following is an example of an impairment-level goal in a physical therapy plan of care?
- Patient will ambulate 500 feet with a rolling walker independently in 4 weeks
- Patient will increase quadriceps strength from 3+/5 to 4+/5 in 3 weeks (Correct answer)
- Patient will return to playing golf 18 holes in 8 weeks
- Patient will demonstrate correct use of home exercise program in 2 weeks
Correct 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.
Question 3: A physical therapist suspects a colleague is documenting treatments that were not actually performed. The MOST appropriate action is to:
- Confront the colleague publicly during a team meeting
- Ignore the situation as it does not involve the therapist's own patients
- Report the concern through the appropriate institutional or regulatory channel (Correct answer)
- Document the suspicion in the therapist's own patient records
Correct 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.
Question 4: When writing a physical therapy discharge summary, which element is MOST critical to include?
- A list of every modality used throughout the episode of care
- The patient's final functional status compared to initial status and goals (Correct answer)
- The therapist's personal opinion of the patient's effort level
- A billing summary of all CPT codes used
Correct 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.
Question 5: 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?
- HIPAA
- FERPA (Correct answer)
- ADA
- IDEA only
Correct 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.
Question 6: The term 'active listening' in patient communication BEST refers to:
- Allowing the patient to speak while the therapist prepares the next question
- Fully concentrating, understanding, and responding to the patient's verbal and non-verbal messages (Correct answer)
- Nodding periodically to show the therapist is present
- Repeating the patient's exact words back verbatim
Correct 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.
Question 7: A physical therapist documents 'patient tolerated treatment well' after a session. This statement is BEST described as:
- Objective and measurable
- Subjective and non-specific (Correct answer)
- A functional outcome measure
- An appropriate assessment statement
Correct 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.
PCE Communication and Documentation 3
A patient with limited English proficiency arrives for their first PT appointment without an interpreter.
The BEST course of action is to: