PTBC (Physical Therapy Board of California) California Law Practice Exam

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What must be included in patient documentation by a Physical Therapist?

  1. Only the evaluation

  2. Evaluation, goals, treatment plan, and summary of treatment

  3. Prescription medications

  4. Diagnostic interpretations

The correct answer is: Evaluation, goals, treatment plan, and summary of treatment

A The correct answer is not A. Patient documentation by a Physical Therapist must include an evaluation, goals, treatment plan, and summary of treatment. The initial evaluation provides a baseline for treatment and helps the therapist create a personalized treatment plan. B: The evaluation is an important part of patient documentation, as it provides a baseline for treatment and allows the therapist to create a personalized treatment plan. Goals should also be included to track the patient's progress and ensure they are receiving appropriate care. The treatment plan outlines the specific therapies and interventions that will be used, while the summary of treatment provides an overall summary of the patient's progress and outcomes. C: Prescription medications are not typically included in patient documentation by a Physical Therapist. This falls under the responsibility of a physician or other healthcare provider who is in charge of prescribing medication for the patient's condition. D: Diagnostic interpretations are not typically included in