Physical Therapy Evaluation and Systems Review
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1
What determines which body structures and functions a physical therapist evaluates?
The patient's activity limitations and their underlying health condition.
2
What are the three core components of a systems review?
A limited examination of 4 body systems, an assessment of communication/cognition/learning, and a movement assessment.
3
Which four anatomical body systems are examined during a physical therapy systems review?
Cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular.
4
What patient capacities are evaluated alongside the four anatomical systems in a systems review?
Communication ability, affect, cognition, language, reading ability, and learning style.
5
What criterion dictates which specific impairments a physical therapist must document?
Results relevant to the current condition and necessary to develop a rationale for diagnosis, goals, and plan of care.
6
Which baseline physical performance categories are routinely evaluated alongside a systems review?
Range of motion, strength, and posture.
7
What type of data should be documented to ensure specificity and avoid ambiguity?
Quantifiable and objective data.
8
When must normal or typical examination findings be documented?
When they are directly relevant to confirming, refuting, or reshaping the diagnosis.
9
What is the target population for the Berg Balance Scale?
Individuals with any neurological condition, older adults, and individuals with balance problems.
10
What does the Berg Balance Scale evaluate?
Balance ability across 14 balance items.
11
What does the Glasgow Coma Scale assess in patients with brain injury?
Alertness and cognitive awareness across eyes, verbal, and motor categories.
12
What does the Numeric Pain Rating Scale measure?
Pain intensity over the past 24 hours on a 0 to 10 scale.
13
What patient response does the Borg Rate of Perceived Exertion scale measure?
Perceived exertion level on a 15-point scale.
14
What is the clinical purpose of the Tinetti Gait and Balance assessment?
A screening tool to identify older adults at risk for falls.
15
What is the most commonly used clinical method to document muscle strength?
Manual Muscle Testing (MMT).
16
What numerical scoring range is used in Manual Muscle Testing?
0 to 5.
17
What instruments provide more reliable and quantitative strength data than manual testing?
Handheld dynamometers or isokinetic dynamometry.
18
What are two examples of functional strength tests?
Sit-To-Stand test and Functional Hop test.
19
Why is documenting range of motion as a single combined span such as \$10^\circ\text{--}150^\circ\$ discouraged?
It creates ambiguity regarding whether it represents AROM or PROM and obscures directional deficits.
20
How should joint range of motion be documented to eliminate ambiguity?
Separate the movement into two distinct directional components and specify AROM or PROM.
21
How is range of motion documented when a joint cannot reach the neutral zero-degree starting value?
As a single negative value.
22
How is a \$10^\circ\$ knee flexion contracture documented for extension?
Knee ext: \$-10^\circ\$.
23
What rule applies to filling out standardized documentation tables and checklists?
No line should ever be left blank.
24
What three acceptable entries can be recorded on a documentation table line?
Examination results/clinical opinion, \$N/T\$ (not tested) with a reason, or \$N/A\$ (not applicable).
25
If a test is marked \$N/T\$, what additional information must be documented?
The clinical reason for omission and a planned date for future evaluation.
26
Why is pain classified as a symptom rather than an impairment in and of itself?
It reflects an underlying impairment in body structure or function rather than being the impairment itself.
27
What does the letter P represent in the PQRST pain documentation mnemonic?
Provokes (what causes the pain, what makes it better, and what makes it worse).
28
What does the letter Q represent in the PQRST pain documentation mnemonic?
Quality (what the pain feels like, such as sharp, dull, stabbing, or burning).
29
What does the letter R represent in the PQRST pain documentation mnemonic?
Region/Radiation (where the pain is located and whether it spreads).
30
What does the letter S represent in the PQRST pain documentation mnemonic?
Severity (intensity of pain rated on a 0 to 10 scale).
31
What does the letter T represent in the PQRST pain documentation mnemonic?
Time (onset, duration, frequency, and whether it is sudden or gradual).
32
What pediatric and nonverbal clinical pain scale uses six cartoon facial expressions?
Wong-Baker FACES Pain Rating Scale.
33
What numerical score on the Wong-Baker FACES Pain Rating Scale corresponds to "Hurts Worst"?
10.
34
What numerical score on the Wong-Baker FACES Pain Rating Scale corresponds to "No Hurt"?
0.
35
Why are the acronyms WNL and WFL considered inadequate in objective impairment documentation?
They lack quantifiable data, specificity, and objective precision.
36
According to the Guide to PT Practice 4.0, what are goals?
The intended impact on functioning as a result of implementing the management plan.
37
Under the Guide to PT Practice 4.0 definition of goals, what three domains define "functioning"?
Body functions and structures, activities, and participation.
38
What are the three essential characteristics of goals according to the Guide to PT Practice 4.0?
Measurable, functionally driven, and time limited.
39
What four individual patient factors must be considered during the goal-setting process?
Core beliefs, personal factors, social factors, and organizational/cultural setting.
40
What three clinical/health elements interact with patient perception to develop the goal core?
Pathology, body structures and function, and activities and participation.
41
Following an intervention, what is assessed relative to the formulated goal?
Goal outcome.
42
What are the six distinct stages in the transtheoretical model of behavior change?
Precontemplation, contemplation, preparation, action, maintenance, and termination.
43
Which stage of change is associated with denial?
Precontemplation.
44
Which stage of change represents establishing a habit?
Maintenance.
45
What drives the time frame chosen for achieving a rehabilitation goal?
The expected time course of rehab.
46
What is the functional relationship of a short-term goal to a long-term goal?
An intermediate step toward the long-term goal.
47
In the SMART goal framework, what does the letter S stand for?
Specific.
48
In the SMART goal framework, what does the letter M stand for?
Measurable.
49
In the SMART goal framework, what does the letter A stand for?
Achievable (or Assignable).
50
In the SMART goal framework, what does the letter R stand for?
Relevant (or Realistic).
51
In the SMART goal framework, what does the letter T stand for?
Time-bound.
52
In the SMART framework, how is "Measurable" defined?
Providing a way to evaluate using quantifiable measures, metrics, or data targets.
53
In the SMART framework, how is "Assignable" defined?
Able to specify who will complete the task.
54
In the SMART framework, how is "Realistic" defined?
Can be achieved with current resources such as personal, physical, and financial.
55
What do participation goals focus on?
The ability to participate in community, leisure, and social activities.
56
What do activity (functional) goals typically focus on?
Specific activities pertinent to a person's life.
57
What do impairment goals specify?
Expected outcomes for specific impairments in body structures or functions contributing to functional limitations.
58
For which patient populations are impairment goals particularly important?
Patients with serious activity limitations, such as immediately after a stroke or spinal cord injury.
59
Are clinical goals defined as outcomes or processes?
Outcomes.
60
With whom should rehabilitation goals be collaboratively determined?
The patient and the patient's family or caregiver.
61
Should clinical goals be concrete or abstract?
Concrete.
62
Why is "Pt. will demonstrate increased control during reaching movements" a poor goal?
It is not functional, concrete, or measurable.
63
What makes a goal predictive?
It is feasible but challenging.
64
What does the acronym ABCDE stand for in the goal-writing formula?
Actor, Behavior, Conditions, Degree, and Expected time.
65
In the ABCDE formula, what is the role of the Actor (A)?
Identify who will accomplish the goal.
66
In the ABCDE formula, what is the role of the Behavior (B)?
Select the expected behavior, task, or functional activity.
67
In the ABCDE formula, what is the role of Conditions (C)?
Determine the context, circumstances, and support needed.
68
In the ABCDE formula, what is the role of Degree (D)?
Determine a quantitative specification of performance.
69
In the ABCDE formula, what is the role of Expected time (E)?
Determine the time period to achieve the goal.
70
Under Conditions (C) in the ABCDE formula, what types of support may be specified?
Physical aids and physical assistance from a caregiver or family member.
71
Under Degree (D) in the ABCDE formula, what three aspects of performance can be quantified?
Consistency, flexibility, and efficiency.
72
In a post-spinal fusion outpatient clinic, what is the target performance for pain-free sitting to allow community transportation?
45 minutes.
73
In a post-spinal fusion outpatient clinic, what is the target performance for pain-free side lying to allow restful sleep?
Up to 8 hours.
74
In a post-spinal fusion outpatient clinic, what is the target performance for stair-climbing for independent household ambulation?
20 stairs, ascend and descend without railing.
75
According to Randall and McEwen (2000), when are people likely to make the greatest gains in therapy?
When therapy and related goals focus on activities related to them that make a difference in their lives.
76
What factors guide the educated estimation of goal time frames?
Health condition, medical history, prognosis, research, clinical judgment, setting, and length of stay.
77
How can the generic goal "Pt. will feed herself independently within 1 wk" be made patient-centered?
Pt. will ind. eat full bowl of dry cereal and milk with a spoon using R hand in 10 min within 1 wk.
78
In the participation goal "Mr. Rasheed will return to work as a bus driver able to accomplish all regular duties within 1 month," what is the Condition (C)?
As a bus driver.
79
In the participation goal "Ms. Samson will return to jogging for fitness and recreation 4x/wk within 2 months," what is the Degree (D)?
4x/wk.
80
In the impairment goal "Strength R shoulder flexion will increase to 4/5 within 3 wk," what is the Condition (C)?
Strength R shoulder flexion.
81
In the impairment goal "Single limb stance on R leg will improve to 10 sec within 2 wk," what is the Degree (D)?
To 10 sec.
82
In the impairment goal "Circumference of R anterior thigh wound will decrease to 2 cm within 4 wk," what is the Expected time (E)?
Within 4 wk.
83
Where is the Plan of Care (POC) located in an Initial Evaluation?
At the end, following Reason for Referral, Activities, Impairments, Assessment, and Goals
84
What is a Plan of Care (POC)?
Detailed overall management strategies to meet goals and guide future sessions
85
What two things does the PT document in the POC regarding interventions?
Interventions to be followed in future sessions and any interventions completed during the examination
86
What are the five main components of a Plan of Care?
PT frequency, coordination/communication, patient related instruction, interventions, and documentation of informed consent
87
What information is stated under PT frequency?
Proposed frequency, duration of visits, and a tentative date for re-evaluation
88
What is an example of PT frequency in an outpatient or home health setting?
\$2\text{x/wk}\$ for 6 wks
89
What is the purpose of documenting coordination and communication?
To record collaboration with other providers, PTAs, caregivers, or family members regarding patient care
90
What is the purpose of patient related instruction in a POC?
Educating the patient or caregiver on wound care, positioning, or home management
91
What are examples of intervention categories that can be included in a POC?
Therapeutic exercise, self-care skills training, and airway clearance
92
How should interventions in a POC flow structurally?
Logically and systematically, tying into goals and ICF limitations
93
What rationale must be demonstrated to third-party payers when documenting interventions?
That the proposed interventions require the expertise of skilled physical therapy
94
Instead of "practice walking on a variety of surfaces," what is a skilled intervention phrase?
Gait training to improve effective foot clearance and maximize safety
95
What are two purposes of documenting informed consent?
Provides evidence that consent was given and serves as a reminder before starting treatment
96
What does the acronym EMR stand for?
Electronic Medical Records
97
Which federal act passed in 2009 promoted the adoption of Electronic Health Records (EHR)?
Health Information Technology for Economic and Clinical Health (HITECH) Act
98
What financial mechanism was used under the HITECH Act to encourage early adoption of EHR?
Incentive payments
99
What two areas of health management were significantly changed by EHR data under the HITECH Act?
Analyzing population health and chronic disease management
100
What are six clinical and administrative areas where EHRs increase efficiency?
Consolidated personalized health records, patient access to records, e-prescribing, electronic authorizations, access to lab/test results, and care coordination
101
Which state statute governs the retention, access, and disclosure of medical records in Texas?
Texas Medical Records Privacy Act (TMRPA)
102
Which entity enforces HIPAA violations and breach notifications in Texas?
Texas Attorney General's Office
103
Which regulatory board may require physical therapists to comply with federal and state privacy/security standards in Texas?
Texas Physical Therapy Board
104
Which chapter of the Texas Health and Safety Code contains the Texas Medical Records Privacy Act?
Chapter 181
105
How does the scope of entities covered by the Texas Medical Records Privacy Act compare to HIPAA?
It applies to a broader range of entities than HIPAA
106
Within how many business days must electronic health record access requests be fulfilled under the Texas Medical Records Privacy Act?
15 business days
107
What is HIPAA's federal timeline standard for fulfilling health record requests?
30 days
108
Within how many days of hire must staff complete privacy training under the Texas Medical Records Privacy Act?
Within 90 days of hire
109
How often must employees complete refresher privacy training under the Texas Medical Records Privacy Act?
Every two years or after significant policy changes
110
Under Texas law, breaches affecting how many Texas residents must be reported to the Texas Attorney General?
250 or more Texas residents
111
Within how many days must any breach affecting any number of individuals be notified under the Texas Medical Records Privacy Act?
Within 60 days
112
What are eight benefits of computerized documentation listed in Box 6.1?
Standardization of data elements, elimination of redundancy, reduction of errors, real-time data accessibility, cost efficiency, outcome measures, improved legibility/confidentiality, and storage
113
What are five potential pitfalls of EMR systems?
Not user-friendly, inaccurate visit/authorization tracking, programming-dependent decision support, pressure to document faster, and excessive template/cloning use
114
What risk occurs when clinicians excessively use templates and automated phrases in an EMR?
Documentation cloning
115
What billing information do stakeholders look for in an EMR to see what was done to a patient?
CPT codes
116
Which web browser is recommended when logging into Prompt EMR?
Google Chrome
117
Which facility must be selected on the Prompt EMR dashboard for the CRU Community Clinic?
CRU Community Clinic: PT
118
Which facility must be selected on the Prompt EMR dashboard for coursework/class training?
Curriculum: PT
119
What sequence of menu clicks is used to access student training modules in Prompt EMR?
Ensure facility is "Curriculum: PT", click "Need help?", then click "Prompt U"
120
What is the title of the training course found within Prompt University for students?
Prompt for Students
121
How many chapters are in the Prompt for Students training curriculum?
14 chapters
122
Which chapter of Prompt University covers creating a case?
Chapter 4
123
Which chapter of Prompt University covers scheduling and check-in?
Chapter 5
124
Which chapter of Prompt University covers documentation in the Document Tab?
Chapter 7
125
Which chapter of Prompt University covers documentation in the Treat & Flow Tab?
Chapter 8
126
Which chapters in Prompt University are listed as optional AI tools and workflows?
Chapter 10 (AI Power Tools) and Chapter 11 (AI-Powered Documentation Walkthroughs)
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