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Which of the following statements about words is most accurate?

Patient-related instructions are documented in the assessment section of the SOAP note. 

You are working with a 5 year old boy who is admitted to the hospital s/p motor vehicle accident (MVA).  He has undergone an open reduction internal fixation (ORIF) to his L tibia and fibula and R humerus.  You are seeing him for physical therapy.  The rating scale most appropriate to use to assess his pain is:

You just completed your SOAP note and realized you forgot to document stair negotiation.  To remedy this issue, you would add and addendum to the note and then sign and date

Why is it important for a PTA to have emotional intelligence?

Where would you document the patient’s pre- and post-treatment vital signs in a SOAP note?

You are working in an outpatient clinic.  Mr. Jacobs, your 2:30 appointment does not show up for his appointment.  The best way to document this in Mr. Jacobs chart is by using the following format:

Where would you document a patient’s report of noncompliance with their home exercise program in a SOAP note?

A physical therapist assistant who clocks in and out each day is considered a non-exempt employee. 

The PT has asked you to see Mr. K this afternoon to instruct him in his HEP and gait with crutches on stairs. When you arrive in the patient’s room, the patient is in the w/c and being taken out to his car. The patient refuses to allow you time for the instruction saying, “All I want to do is get out of this hospital.” Write a note that you would enter into the medical record for this patient based upon the above scenario. (2 points)