Intro to PT 1409 Unit II Exam || with 100% Verified Solutions.
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Course
PT 1409
Institution
PT 1409
3 Essentials Principles of Documentation correct answers Accuracy -Avoid General Statements, be complete with your statements
Brevity - Concise and to the point, give info to leave no doubt
Clarity - Immediately clear to reader. HW is legible.
SOAP Note was introduced in the ______ by Dr. ____...
Intro to PT 1409 Unit II Exam || with 100% Verified
Solutions.
3 Essentials Principles of Documentation correct answers Accuracy -Avoid General Statements,
be complete with your statements
Brevity - Concise and to the point, give info to leave no doubt
Clarity - Immediately clear to reader. HW is legible.
SOAP Note was introduced in the ______ by Dr. _______, dubbed a ______ correct answers
60s, Lawrence Reed, POMR.
Content of the POMR correct answers Database (current and past information about the patient)
Problem List (Problems to be treated)
Identification (Specific treatment plan)
Assessment (effectiveness of the treatment plan)
Content of the physical therapy note (SOAP Note) correct answers S: Subjective: Info Gathered
from the interview
O: Objective: Information gathered during the intervention
A: Assessment: of Patient during and after treatment
P: Plan: What treatment is planned and its progression
Initial Note correct answers Done by primary care physician, specialist nurse, PT, OT, Speech
therapist.
Progress Note correct answers Written Periodically, Includes daily visits, interventions, and
reassessments. Frequency determined by facility (may be daily, weekly, biweekly, monthly) 3rd
party payers require progress notes after every treatment.
Discharge Note correct answers Written when therapy is discontinued; after a final exam and
eval are performed. The DC note will give the results of the final examination and evaluation, the
goals achieved (or not achieved and why) and a summary of interventions received. Will give
recommendations by provider or a discharge plan.
Purposes of Documentation (6) correct answers Assists in better treatment planning
Improved communications b/w the disciplines
Scrutinized by Funding Sources to say yay or nay to services
Medical Record are Primary Source Of Info in Litigation
Assess Quality of Care
Provides Data For Research
Assists in Decision Making for PTA
Access Longitudinal info on Pt
S of SOAP note Ex. correct answers Patient reports pain in R hip 6/10 during supported standing
and 4/10 with bed activities. Patient states that she is afraid she will fall.
, O of SOAP note Ex. correct answers Bed Activities: Patient performed bed mobility and sitting
at B/S c (with) min assist x 1. Transfer activities: Performed standing transfer x 1 from mat >
W/C (c) mod assist x 1.
A of SOAP note Ex. correct answers Patient is currently unable to perform transfers w/o at least
mod. assist. Patient will benefit from skilled interventions to improve progress toward goals of I
bed mobility, transfers, and gait. Presence of family seems to motivate patient during treatment.
SOAP Note STO 2 Examples : correct answers #1. Patient will perform pivot transfer
independently (i) next session in order to get OOB.
#2. Patient will perform I bed mobility in one week so patient can function safely at home.
P of SOAP Notes Ex. correct answers Instruct family in transfer techniques and initiate HEP for
LE strengthening. Initiate GT in || bars.
Signing a SOAP Note correct answers David L. Bregger, SPTA; Supervising physical therapist
Karen Jones.
Long Term Goals correct answers Written for extended time frames, i.e. months
Helps to plan the treatment and guide the POC
Short Term Goals correct answers Written in shorter time frames, treatment sessions of 1 to 2
week. Direct treatment to specific needs and problems.
6 Criteria For Goals correct answers 1)Audience: Who Will exhibit the skill-Pt. when possible or
family member.
2)Behavior: What is the Activity? What will the person do?
3)Condition: Circumstances involved with the behavior. (position, equipment, etc.)
4)Degree: The measurable portion- feet, number of times, amount of assistance, etc.
5)Expected: Time to reach goal or objective
6) Function: What should they be able to do when goal met?
Goals Are Written to: (4) correct answers 1)Prioritize the treatment
2)Measure the effectiveness of treatment
3)Used to monitor cost-effectiveness
4)Communication with other healthcare providers about the course of care.
Teaching (def) correct answers To impart knowledge of skill in; give instruction in
Learning correct answers The act or process of acquiring knowledge or skill.
Cognitive Style correct answers The preferred way an individual processes information and
describes a person's typical mode of thinking.
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