PTA 220 Final Exam with all Correct & 100% Verified
Answers |Actual Complete Update |Already Graded A+
Documentation ✔Correct Answer-Professional responsibility & a legal requirement
throughout episode of care. Also helps support payment of services.
What are the 6 purposes of PT documentation? ✔Correct Answer-1. Serves as a record of
pt./client care.
2. Provides historical account of pt./client encounters that can be used as evidence in potential
legal situations.
3. Demonstrates compliance with federal, state, payer & local regulations.
4. Demonstrates appropriate service utilization & reimbursement from many third party payers.
5. Policy or research purposes including outcomes analysis & quality assurance.
6. Tells others about our abilities, our unique body of knowledge & services provide as PT/PTA's.
What 3 forms of recording provide assurance of quality patient care? ✔Correct Answer-1.
Recording baseline information for future evaluative comparisons.
2. Recording progress in pt. performance or change in condition.
3. Recording information pertinent to discharge/discontinuation.
2 methods used to record baseline information for future evaluative comparisons? ✔Correct
Answer-1. Initial exam/initial evaluation
2. Re-examination
Elements of an initial exam/initial evaluation? (7 things) ✔Correct Answer-History, Systems
review, tests & measures, evaluation, diagnosis, prognosis, & plan of care.
Re-examination occurs when there is: (3 things) ✔Correct Answer-1. An unanticipated change
in pt's condition.
2. Failure to respond to PT as expected.
3. The need for a new POC based on practice acts or other requirements.
Primary method used to record progress in pt. performance or change in condition? ✔Correct
Answer-Visit/Encounter Note (AKA Daily Note)
Visit/Encounter notes document implementation of the POC established by the PT & it includes:
(8 things) ✔Correct Answer-1. Changes in status
2. Pt. or caregiver report
3. Interventions/equipment provided
4. Variations/progressions of certain interventions
5. Frequency, intensity, & duration.
,6. Communication w/other providers, pt., caregivers. (Ex. Make a note if you speak to the PT
about care)
7. Factors that modify interventions or progressions of goals.
8. Plan for next visit.
Recording information pertinent to discharge/discontinuation includes: (3 things) ✔Correct
Answer-1. Equipment needs and/or ordered.
2. Recommendations for follow-up care.
3. Level of performance/progress at time of discharge/discontinuation.
Discharge: ✔Correct Answer-The process of ending PT services that have been provided
during a single episode of care, when the anticipated GOALS & expected OUTCOMES have been
ACHIEVED.
Discontinuation is the process of ending PT services that have been provided during a single
episode of care when... (3 things) ✔Correct Answer-1. The pt., caregiver, or legal guardian
declines to continue intervention.
2. The pt. is unable to continue to progress towards goals & outcomes because of medical or
psychosocial complications or because financial resources have been expended.
3. The PT determines that the pt. will no longer benefit from PT.
If PTA's write discharge notes, both planning & documentation should be done with input from
who? ✔Correct Answer-The supervising PT
What's a discharge summary? ✔Correct Answer-A summary of the content of notes already
written on the pt. (Ex. Interventions provided, pt. response, etc.)
Can PTA's write Discharge Summary's? ✔Correct Answer-Yes, but the final documentation
must still be done by the PT.
What's a discharge evaluation? ✔Correct Answer-New info is gathered and/or planning &
recommendations based on already gathered info related to discharge of pt. (Ex. Plans for pt.
after discharge, home evaluation, family education, etc.)
What are the 3 most common errors in failures to document? ✔Correct Answer-1. Failure to
document actions taken.
2. Failure to document the actions NOT taken.
3. Failure to document reasons supporting your judgments.
In court, if you did not document it, then... ✔Correct Answer-You did not do it!
The KEY to reimbursement now is showing what? ✔Correct Answer-Functional progress
, Documenting Skilled Care looks like... (5 things) ✔Correct Answer-1. Clinical decision
making/problem solving process.
2. Indicate why you chose the interventions/why tbey are necessary.
3. Document interventions connected to the impairment/functional limitation.
4. Document interventions connected to goals in POC.
5. Document complications of comorbitities, safety issues, etc.
Documenting Medical Necessity= (4 things) ✔Correct Answer-1. Service is consistent with
nature and severity of illness l, injury, medical needs.
2. Service is specific, safe, & effective according to accepted medical practice.
3. Reasonable expectation of measurable improvement in function.
4. Service do NOT JUST promote the general welfare of pt.
Documenting Progress includes... (4 things) ✔Correct Answer-1. Update pt. goals regularly
2. Highlight progress toward goals
3. Show comparisons from previous to current date
4. Show a focus on function
Top 10 Payer Complaints/Reasons for Denial? ✔Correct Answer-1. Poor legibility
2. Incomplete documentation
3. No documentation for date of service
4. Abbreviations- too many & cannot understand
5. Documentation doesn't support the billing code
6. Does not demonstrate skilled care
7. Does not support medical necessity
8. Does not demonstrate progress
9. Repetitious daily notes showing no change in pt. status
10. Interventions with no clarification of time, frequency, or duration.
"Buzz Words" are effective or ineffective for reimbursement? ✔Correct Answer-Effective!
Name 10 "buzz words" that are effective for reimbursement from Medicare & other third party
payers. ✔Correct Answer-1. Change in condition or mental status
2. Safety
3. Danger or recurrence
4. Functional skills
5. Promote recovery
6. Enable independent behavior
7. Prior level was...current level is...
8. Skilled level of care
9. Requires verbal & tactile cues
10. "To teach safe transfers" rather than "to prevent falls"
Answers |Actual Complete Update |Already Graded A+
Documentation ✔Correct Answer-Professional responsibility & a legal requirement
throughout episode of care. Also helps support payment of services.
What are the 6 purposes of PT documentation? ✔Correct Answer-1. Serves as a record of
pt./client care.
2. Provides historical account of pt./client encounters that can be used as evidence in potential
legal situations.
3. Demonstrates compliance with federal, state, payer & local regulations.
4. Demonstrates appropriate service utilization & reimbursement from many third party payers.
5. Policy or research purposes including outcomes analysis & quality assurance.
6. Tells others about our abilities, our unique body of knowledge & services provide as PT/PTA's.
What 3 forms of recording provide assurance of quality patient care? ✔Correct Answer-1.
Recording baseline information for future evaluative comparisons.
2. Recording progress in pt. performance or change in condition.
3. Recording information pertinent to discharge/discontinuation.
2 methods used to record baseline information for future evaluative comparisons? ✔Correct
Answer-1. Initial exam/initial evaluation
2. Re-examination
Elements of an initial exam/initial evaluation? (7 things) ✔Correct Answer-History, Systems
review, tests & measures, evaluation, diagnosis, prognosis, & plan of care.
Re-examination occurs when there is: (3 things) ✔Correct Answer-1. An unanticipated change
in pt's condition.
2. Failure to respond to PT as expected.
3. The need for a new POC based on practice acts or other requirements.
Primary method used to record progress in pt. performance or change in condition? ✔Correct
Answer-Visit/Encounter Note (AKA Daily Note)
Visit/Encounter notes document implementation of the POC established by the PT & it includes:
(8 things) ✔Correct Answer-1. Changes in status
2. Pt. or caregiver report
3. Interventions/equipment provided
4. Variations/progressions of certain interventions
5. Frequency, intensity, & duration.
,6. Communication w/other providers, pt., caregivers. (Ex. Make a note if you speak to the PT
about care)
7. Factors that modify interventions or progressions of goals.
8. Plan for next visit.
Recording information pertinent to discharge/discontinuation includes: (3 things) ✔Correct
Answer-1. Equipment needs and/or ordered.
2. Recommendations for follow-up care.
3. Level of performance/progress at time of discharge/discontinuation.
Discharge: ✔Correct Answer-The process of ending PT services that have been provided
during a single episode of care, when the anticipated GOALS & expected OUTCOMES have been
ACHIEVED.
Discontinuation is the process of ending PT services that have been provided during a single
episode of care when... (3 things) ✔Correct Answer-1. The pt., caregiver, or legal guardian
declines to continue intervention.
2. The pt. is unable to continue to progress towards goals & outcomes because of medical or
psychosocial complications or because financial resources have been expended.
3. The PT determines that the pt. will no longer benefit from PT.
If PTA's write discharge notes, both planning & documentation should be done with input from
who? ✔Correct Answer-The supervising PT
What's a discharge summary? ✔Correct Answer-A summary of the content of notes already
written on the pt. (Ex. Interventions provided, pt. response, etc.)
Can PTA's write Discharge Summary's? ✔Correct Answer-Yes, but the final documentation
must still be done by the PT.
What's a discharge evaluation? ✔Correct Answer-New info is gathered and/or planning &
recommendations based on already gathered info related to discharge of pt. (Ex. Plans for pt.
after discharge, home evaluation, family education, etc.)
What are the 3 most common errors in failures to document? ✔Correct Answer-1. Failure to
document actions taken.
2. Failure to document the actions NOT taken.
3. Failure to document reasons supporting your judgments.
In court, if you did not document it, then... ✔Correct Answer-You did not do it!
The KEY to reimbursement now is showing what? ✔Correct Answer-Functional progress
, Documenting Skilled Care looks like... (5 things) ✔Correct Answer-1. Clinical decision
making/problem solving process.
2. Indicate why you chose the interventions/why tbey are necessary.
3. Document interventions connected to the impairment/functional limitation.
4. Document interventions connected to goals in POC.
5. Document complications of comorbitities, safety issues, etc.
Documenting Medical Necessity= (4 things) ✔Correct Answer-1. Service is consistent with
nature and severity of illness l, injury, medical needs.
2. Service is specific, safe, & effective according to accepted medical practice.
3. Reasonable expectation of measurable improvement in function.
4. Service do NOT JUST promote the general welfare of pt.
Documenting Progress includes... (4 things) ✔Correct Answer-1. Update pt. goals regularly
2. Highlight progress toward goals
3. Show comparisons from previous to current date
4. Show a focus on function
Top 10 Payer Complaints/Reasons for Denial? ✔Correct Answer-1. Poor legibility
2. Incomplete documentation
3. No documentation for date of service
4. Abbreviations- too many & cannot understand
5. Documentation doesn't support the billing code
6. Does not demonstrate skilled care
7. Does not support medical necessity
8. Does not demonstrate progress
9. Repetitious daily notes showing no change in pt. status
10. Interventions with no clarification of time, frequency, or duration.
"Buzz Words" are effective or ineffective for reimbursement? ✔Correct Answer-Effective!
Name 10 "buzz words" that are effective for reimbursement from Medicare & other third party
payers. ✔Correct Answer-1. Change in condition or mental status
2. Safety
3. Danger or recurrence
4. Functional skills
5. Promote recovery
6. Enable independent behavior
7. Prior level was...current level is...
8. Skilled level of care
9. Requires verbal & tactile cues
10. "To teach safe transfers" rather than "to prevent falls"
