Informed consent is not part of the medical record. 

In order to have effective therapeutic communication, the healthcare provider must understand the patient’s needs, must keep the patient’s therapeutic needs in mind, must make appropriate clinical judgments, and must facilitate effective therapeutic communication in patient/practitioner interactions.

Select the appropriate portion of the SOAP note for the following statement: The patient completed 10 reps/3 sets of hip flex against max. resistance today. 

Legal proceedings take multiple forms. Identify the word that matches the definition: this proceeding does not occur in a courtroom, both lawyers are present, and a court reporter or tape recorder is used. 

Select the appropriate portion of the SOAP note for the following statement: Patient now able to reach items on highest kitchen shelf which was not possible initially.

Read the case below. Determine the appropriate CPT codes for billing and the number of units to bill for each CPT code, including time if appropriate (4 points).   History and Physical Therapy Information Patient is a 52 y/o female referred to a PT clinic with a diagnosis of right lumbar muscular strain. During the previous PT session 3 days ago, the patient ambulated with an antalgic pattern involving the right lower extremity. The patient complained of pain radiating from the right lumbar region to the right gluteal region. The patient was independent with sit-to-stand transfers but relied on her arms to push up from a chair. The patient is being treated by the SPTA in physical therapy today. At 15:13, the start of today’s session, the patient complained of pain in the right lumbar region especially with bending forward. The pt. flexed her spine and c/o pain when drinking water at the water fountain in the clinic. During today’s session, the SPTA provided instruction regarding maintaining a neutral spine while flexing at the hips in standing. The SPTA provided manual massage to the right quadratus lumborum. Pt. denied pain when bending forward at her hips after the modality. Today’s treatment also involved teaching the patient a home exercise to stretch hamstrings in supine, 3 repetitions of 30 seconds, 3-4 times per day. At the start of today’s treatment session, the patient was independent with sit-to-stand transfers using her lower extremities and not relying on her arms. At the start of today’s treatment session, patient attempted ambulation with symmetrical weight-bearing during stance phase of the right and left lower extremities for 400 ft, but after 300 ft. pt. demonstrated a slight decrease in stance phase time for the right lower extremity. At 15:52, the end of today’s treatment session, the patient demonstrated that she could maintain a neutral spine while bending at the hips in standing, and she demonstrated independence with hamstring stretching.   STGs that have been established for this patient include: Pt. will ambulate (I) without an antalgic gait pattern x 500’ in 3 weeks. Pt. will transfer sit-to-stand (I) using only the lower extremities in 1 week. Pt. will maintain a neutral spine when performing ADLs that involve sitting, standing, squatting, and lifting within 2 weeks.

Select the appropriate portion of the SOAP note for the following statement: The patient’s daughter said that she is going to buy him a shower chair when he is discharged from the hospital so he can take a shower by himself.

List and define five of the seven effective listening techniques. (extra credit-Provide an example of how you would use two of the techniques)

In the following goal, which component(s) are missing? Select all that apply. Pt. transfers in 2 weeks

A judgment about the level of optimal improvement the patient may attain, and the amount of time needed to reach that level is the definition of: