PTHA 1409 EXAM 2 UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS
Question:
1. what principle of documentation is true; objective; correct spelling and grammar
Answer:
Accuracy
Question:
2. what principle of documentation is concise and to the point; give enough information so as to leave no
doubt; abbreviations may help with brevity; use short concise sentences.
Answer:
Brevity
Question:
3. what principle of documentation is meaning is immediately clear to the reader; do not shift tenses;
handwriting is legible.
Answer:
Clarity
Question:
4. Identify the content of the problem-oriented medical record.
Answer:
Database: current and past information about the patient Problem list: problems to be treated by various
practitioners. Identification of a specific treatment plan by each provider on the case. Assessment of
effectiveness of the treatmentplan across time.
Question:
5. Explain the purposes of the S-subjective in SOAP notes
Answer:
information provided by the patient, family, or caregiver to you. Focus on statements related to prior
function, current level of function, reported barriers to achieve function, and compliance with treatment.
Must be relevant to patients' current condition. Try not to refer to pt as a place, disease, or disability. Use
direct quotes to demonstrate pt denial/non-compliance, attitude, abusive language, or intent to manipulate
or defraud, regressive traits. i.e., confusion or loss of memory.
Question:
6. Explain the purposes of the O OBJECTIVE: in SOAP notes
Answer:
what is done during treatment including interventions and data collection related to the interventions;
measureable; any activity performed by pt during treatment; charts/tables, flowsheets, photos/video
Question:
7. Explain the purposes of the AA
- ASSESSMENT in SOAP notes
,Answer:
assessment of patient during and after treatment; why does pt need to continue PT, why should an
insurance company pay you to do it, how did the pt perform during tx, how does their performance affect
their functional status, why is your opinion regarding pt progress?
Question:
8. Explain the purposes of the P-PLAN in SOAP notes
Answer:
used to outline the plan for future sessions. The therapist should report on what the pt's HEP will consist
of, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy
are documented here. Questions to ask: needs of next visit, repeat, or do tests, treatment progression, stuff
to discuss with PT, possible re-evaluation
Question:
9. What are the differences between the Initial note, as they pertain to physical therapy?
Answer:
done by primary care physician, specialist nurse, PT, OT, speech therapist.Examination, Evaluation,
Diagnosis, Prognosis, Plan of care (POC)
Question:
10. What are the differences between the progress/daily note, as they pertain to physical therapy?
Answer:
Written periodically Includes: daily visits, interventions, and reassessments. Frequency determined by
facility (may be daily, weekly, biweekly, or monthly)3rd party payers require progress notes after every
treatment
Question:
11. What are the differences between the re-evaluation note, as they pertain to physical therapy?
Answer:
Patient's treatments, progress related to goals and updated POC and goals if needed
Question:
12. What are the differences between the discharge note, as they pertain to physical therapy?
Answer:
Written when therapy is discontinued; after a final examination and evaluation are performed The DC note
will give the results of the final examination and evaluation, the goals achieved (or not achieved and why)
A summary of interventions received. The DC note will give recommendations by provider or a discharge
plan.
Question:
13. Identify the seven purposes for documentation.
, Answer:
1)To keep record of patient care
2)To communicate between health care professionals
3)Provides information or justification to third party payers; used to make decisions regarding
reimbursement
4)Assists in decision-making; PT, PTA, and primary physician communicate regarding plan of care and
discharge
5)The format provides a method to organize patient information to assist the physical therapist in clinical
decision-making
6)Provides data for quality assurance and improvement of patient care
7)Provides data for research
Question:
14. The assessment part of a SOAP note
Answer:
professional interpretation of the patient's symptoms, complaints, and observable signs. It is where you
document your findings and assessments related to the patient's condition
Question:
15. The subject part of a soap notes
Answer:
the patient's self-reported information about their condition and symptoms.
Question:
16. The objective part of a soap note
Answer:
captures measurable, observable, and factual data obtained during the patient's examination.
Question:
17. the plan part of a soap note
Answer:
outlines the treatment plan for the client, short- and long-term goals, and expectations for future sessions.
Question:
18. Which goal is written for extended time frames, i.e. months. Helps to plan the treatment and guide to
the POC
Answer:
Long term goals
Question:
19. which goal is written in shorter time frames, treatment sessions of 1 to 2 weeks. Direct treatment to
specific needs and problems.
Answer:
Short term goals
Question:
20. Explain the purposes for writing goals in physical therapy.
CORRECT ANSWERS
Question:
1. what principle of documentation is true; objective; correct spelling and grammar
Answer:
Accuracy
Question:
2. what principle of documentation is concise and to the point; give enough information so as to leave no
doubt; abbreviations may help with brevity; use short concise sentences.
Answer:
Brevity
Question:
3. what principle of documentation is meaning is immediately clear to the reader; do not shift tenses;
handwriting is legible.
Answer:
Clarity
Question:
4. Identify the content of the problem-oriented medical record.
Answer:
Database: current and past information about the patient Problem list: problems to be treated by various
practitioners. Identification of a specific treatment plan by each provider on the case. Assessment of
effectiveness of the treatmentplan across time.
Question:
5. Explain the purposes of the S-subjective in SOAP notes
Answer:
information provided by the patient, family, or caregiver to you. Focus on statements related to prior
function, current level of function, reported barriers to achieve function, and compliance with treatment.
Must be relevant to patients' current condition. Try not to refer to pt as a place, disease, or disability. Use
direct quotes to demonstrate pt denial/non-compliance, attitude, abusive language, or intent to manipulate
or defraud, regressive traits. i.e., confusion or loss of memory.
Question:
6. Explain the purposes of the O OBJECTIVE: in SOAP notes
Answer:
what is done during treatment including interventions and data collection related to the interventions;
measureable; any activity performed by pt during treatment; charts/tables, flowsheets, photos/video
Question:
7. Explain the purposes of the AA
- ASSESSMENT in SOAP notes
,Answer:
assessment of patient during and after treatment; why does pt need to continue PT, why should an
insurance company pay you to do it, how did the pt perform during tx, how does their performance affect
their functional status, why is your opinion regarding pt progress?
Question:
8. Explain the purposes of the P-PLAN in SOAP notes
Answer:
used to outline the plan for future sessions. The therapist should report on what the pt's HEP will consist
of, as well as the steps to take in order to reach the functional goals. Changes to the intervention strategy
are documented here. Questions to ask: needs of next visit, repeat, or do tests, treatment progression, stuff
to discuss with PT, possible re-evaluation
Question:
9. What are the differences between the Initial note, as they pertain to physical therapy?
Answer:
done by primary care physician, specialist nurse, PT, OT, speech therapist.Examination, Evaluation,
Diagnosis, Prognosis, Plan of care (POC)
Question:
10. What are the differences between the progress/daily note, as they pertain to physical therapy?
Answer:
Written periodically Includes: daily visits, interventions, and reassessments. Frequency determined by
facility (may be daily, weekly, biweekly, or monthly)3rd party payers require progress notes after every
treatment
Question:
11. What are the differences between the re-evaluation note, as they pertain to physical therapy?
Answer:
Patient's treatments, progress related to goals and updated POC and goals if needed
Question:
12. What are the differences between the discharge note, as they pertain to physical therapy?
Answer:
Written when therapy is discontinued; after a final examination and evaluation are performed The DC note
will give the results of the final examination and evaluation, the goals achieved (or not achieved and why)
A summary of interventions received. The DC note will give recommendations by provider or a discharge
plan.
Question:
13. Identify the seven purposes for documentation.
, Answer:
1)To keep record of patient care
2)To communicate between health care professionals
3)Provides information or justification to third party payers; used to make decisions regarding
reimbursement
4)Assists in decision-making; PT, PTA, and primary physician communicate regarding plan of care and
discharge
5)The format provides a method to organize patient information to assist the physical therapist in clinical
decision-making
6)Provides data for quality assurance and improvement of patient care
7)Provides data for research
Question:
14. The assessment part of a SOAP note
Answer:
professional interpretation of the patient's symptoms, complaints, and observable signs. It is where you
document your findings and assessments related to the patient's condition
Question:
15. The subject part of a soap notes
Answer:
the patient's self-reported information about their condition and symptoms.
Question:
16. The objective part of a soap note
Answer:
captures measurable, observable, and factual data obtained during the patient's examination.
Question:
17. the plan part of a soap note
Answer:
outlines the treatment plan for the client, short- and long-term goals, and expectations for future sessions.
Question:
18. Which goal is written for extended time frames, i.e. months. Helps to plan the treatment and guide to
the POC
Answer:
Long term goals
Question:
19. which goal is written in shorter time frames, treatment sessions of 1 to 2 weeks. Direct treatment to
specific needs and problems.
Answer:
Short term goals
Question:
20. Explain the purposes for writing goals in physical therapy.
