Charting & Documentation
Identify the SOAP notes section used for patient-reported pain.
Subjective section
Give the typical adult resting pulse range.
60-100 bpm
What pressure injury stage has red, non-blanchable skin?
Stage 1
What is the first priority before beginning CPR
Ensure scene safety
What do CPT codes describe?
services or procedures performed
In a SOAP note, which section contains measurable observations, such as range of motion?
Objective section
How should a regular pulse be counted when using the 30-second method.
Count beats in 30 seconds and then multiply by 2.
What should you do if blood soaks thorugh the first dressing during external bleeding control?
Add more layers without removing the original dressing.
What is the compression-to-breath ratio for a single rescuer helping an adult?
30:2
What does an ICD-10 code describe?
diagnosis or patient condition
A patient reports pain, and a clinician measures limited joint motion. Identify which finding is subjective?
The patient reporting pain
State the adult respiratory rate range that should be reported if the rate falls below it.
rate below 12 breaths per minute
Which dressing type is identified for wounds with moderate exudate?
foam dressings
Name two signs of shock.
clammy, pale, or cold skin, rapid weak pulse, increased or shallow breathing, blank facial expression
What must be verified before physical therapy services are provided?
Active coverage, physical therapy benefits, referral requirements
What does EHR stand for?
Electronic Health Record
A patient's blood pressure is 146/92 mmHg. According to the study guide what should the technician do?
Report the blood pressure to the supervising PT
Describe how to clean a wound, including the direction of cleaning.
gently clean from the center outward with gentle saline
For two rescuers performing CPR on an infant, what is the compression-to-breath ration?
15:2
What is the difference between a copayment and a deductible?
Copayment is fixed fee paid for a visit
Deductible is the annual cost out-of-pocket that must be paid before insurance begins to cover costs
The clinician notating swelling and bruising in the patient's ankle.
Which of the following should the technician do if a patient says they are feeling dizzy? 1. immediately tell a supervisor 2. have the patient continue therapy 3. document in patient EHR 4. ask another patient what to do 5. tell all coworkers
1 and 3
Name three signs of infection that should be reported to a supervisor immediately?
redness, warmth, swelling, pus, foul-smelling drainage, fever, chills, increased pain, wound breakdown, delayed healing
An unresponsive person is only gasping, an no pulse is detected within 10 seconds. What should the rescuer do next?
begin CPR
A physical therapy clinic provides treatment, but the session details are missing from the patient’s record. Why could this create a billing problem?
Lack of documentation of service
If an activity or service is not documented, it is considered not to have been performed