PTHA 1409, UNIT 2, EXAM 2 (SOLVED) CORRECTLY TO
SCORE A+
Principles of Documentation Answer - Accuracy: objective; true; spelling and
grammar
Brevity: short and sweet; abbr.; no doubt
Clarity: meaning is clear; no personal pronouns; legible
Name
Dx
History
Signed, SPTA, supervising PT, _________, PT
single line through spaces and errors
document promptly
content of problem-oriented medical record Answer - database: current and
past info
problem list: treated by various practitioners, each writes own note
identification of treatment plan
assessment of treatment plan across time
purpose of 4 part SOAP note Answer - Subjective: personal info on pt by pt or
family
Objective: data and measurements during visit
, Assessment: how O went, how it realates to goals; feelings during O; show
progress or lack there of
Plan: specifics for moving forward (discuss w/ PT)
initial note / progress note / discharge note for PT Answer - Initial note: PT
eval; diagnosis; prognosis; POC
Progress note: PT summarize pt progress related to goals
Discharge note: PT final exam/eval; goal achieved, or not and why; summary of
interventions used; DC will give recommendations of discharge plan
Identify 7 purposes for documentation Answer - -record of pt care
-communication
-info and justification to payers regarding reimbursement
-helps w/ decision-making; PT/PTA/PCP communication regarding POC and
discharge
-format is a method to organize
-provides data for quality assurance and improved pt care
-research
classify statements in SOAP notes Answer - S: pt says "-"
O: data measurements
A: what was seen during tx (even signs of pain); performance notes; is pt
making goals towards progress or not
P: what pt needs based on performance of that session
(use abbreviations )
short term vs long term goals Answer - LTG: corresponds to problem list; states
final status to be achieved; helps to plan treatment and guide POC
SCORE A+
Principles of Documentation Answer - Accuracy: objective; true; spelling and
grammar
Brevity: short and sweet; abbr.; no doubt
Clarity: meaning is clear; no personal pronouns; legible
Name
Dx
History
Signed, SPTA, supervising PT, _________, PT
single line through spaces and errors
document promptly
content of problem-oriented medical record Answer - database: current and
past info
problem list: treated by various practitioners, each writes own note
identification of treatment plan
assessment of treatment plan across time
purpose of 4 part SOAP note Answer - Subjective: personal info on pt by pt or
family
Objective: data and measurements during visit
, Assessment: how O went, how it realates to goals; feelings during O; show
progress or lack there of
Plan: specifics for moving forward (discuss w/ PT)
initial note / progress note / discharge note for PT Answer - Initial note: PT
eval; diagnosis; prognosis; POC
Progress note: PT summarize pt progress related to goals
Discharge note: PT final exam/eval; goal achieved, or not and why; summary of
interventions used; DC will give recommendations of discharge plan
Identify 7 purposes for documentation Answer - -record of pt care
-communication
-info and justification to payers regarding reimbursement
-helps w/ decision-making; PT/PTA/PCP communication regarding POC and
discharge
-format is a method to organize
-provides data for quality assurance and improved pt care
-research
classify statements in SOAP notes Answer - S: pt says "-"
O: data measurements
A: what was seen during tx (even signs of pain); performance notes; is pt
making goals towards progress or not
P: what pt needs based on performance of that session
(use abbreviations )
short term vs long term goals Answer - LTG: corresponds to problem list; states
final status to be achieved; helps to plan treatment and guide POC
