7.3 Patient Safety, Emergency Response & Documentation

Falls Prevention During Treatment

Falls are the most common preventable adverse event in physical therapy, and the PTA controls fall risk before and during every session:

• Use a gait belt for all ambulation and transfer training — apply it snugly over clothing at the waist, never around bare skin, an abdominal incision, or a feeding tube.
• Scan the environment for tripping hazards: clutter, cords, throw rugs, wet floors, and poor lighting.
• Check footwear — non-skid, closed-back, properly fitted shoes; treat barefoot or socks-only ambulation as a hazard.
• Lock wheelchair and bed brakes before every transfer and confirm equipment (walker, oxygen tubing) is within reach.
• Guard on the patient's weaker or more affected side and stay slightly behind, with one hand on the gait belt.

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Emergency Response

Syncope and Cardiac Arrest

If a patient faints or collapses:

1. Call for help — activate the facility code or 911.
2. Position the patient supine; elevating the legs aids venous return if simple syncope is suspected.
3. Check responsiveness and pulse. If pulseless, begin CPR immediately.
4. Apply an AED as soon as one is available and follow its voice prompts.

High-quality cardiopulmonary resuscitation (CPR) means chest compressions at 100 to 120 per minute, a depth of about 2 inches (5 cm) in adults, full recoil between compressions, and minimal interruptions. An automated external defibrillator (AED) analyzes the rhythm and delivers a shock only if a shockable rhythm is detected.

Choking

For a conscious adult with a complete airway obstruction (cannot speak, cough, or breathe), deliver abdominal thrusts (Heimlich maneuver) until the object is expelled or the patient becomes unresponsive — then lower them to the floor, call for help, and begin CPR. For a partial obstruction with effective coughing, encourage continued coughing and do not intervene.

Seizure Response

• Do NOT restrain the patient and do NOT put anything in the mouth.
• Lower the patient to the floor, protect the head (cushion it), and clear nearby hazards and equipment.
• Time the seizure — an event lasting longer than 5 minutes, or repeated seizures without recovery, is status epilepticus, a medical emergency.
• When the seizure ends, place the patient in a side-lying recovery position to protect the airway, and monitor through the post-ictal phase until fully alert.

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Incident Reporting

Any fall, equipment failure, or adverse event requires a factual incident report completed promptly. Document objectively what happened — not opinions, blame, or speculation about cause. The incident report is an internal risk-management document and is generally NOT filed in the patient's medical chart, and the chart should not reference that a report was filed.

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SOAP Documentation

PTAs document each treatment session using the SOAP format:

Every PTA note must be signed by the PTA with credentials and the date. Under Medicare, a PTA's daily treatment notes do not require routine PT countersignature. However, the PT must write and sign a progress report at least every 10 treatment days or once every 30 calendar days, whichever is less. The PTA may write portions of a progress report, but a PTA-only document is not a complete progress report — the licensed PT must perform the re-assessment that justifies continued medical necessity.

Vital Sign Red Flags That Stop Treatment

A PTA must monitor responses and know when to hold an intervention and notify the PT or call for help. Memorize these stop signs:

Rate of perceived exertion is commonly tracked with the Borg scale (6–20) or the modified Borg (0–10); a moderate target is roughly 11–14 on the 6–20 scale. If a red flag appears, stop, assess, position safely, take vitals, and escalate — do not push through symptoms to finish the planned sets.

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Documentation Standards and Defensibility

Beyond SOAP structure, the exam tests sound documentation habits:

• Write objectively and contemporaneously; never document an intervention before it is performed.
• Use standard abbreviations only; avoid error-prone ones.
• Never erase or use correction fluid on a paper record. Draw a single line through an error, initial and date it, and write the correction — alterations that hide the original create legal liability.
• Each entry needs the date, the PTA's signature, and credentials.
• Medical necessity language matters: notes should show skilled care (why a PTA/PT is needed) and progress toward measurable goals, because reviewers deny claims that read as unskilled, repetitive, or maintenance-only without justification.

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Worked Scenario

Midway through gait training, a patient becomes pale, lightheaded, and reports the room is spinning; the PTA measures a 25 mmHg systolic drop from sitting to standing. The correct sequence: stop ambulation, ease the patient to a safe seated or supine position, monitor vitals and symptoms, and notify the supervising PT and nursing. The PTA documents the objective findings, the action taken, and the response in the SOAP note, and completes an incident report if a fall or near-fall occurred.

The PTA does not independently change the POC — but recognizing the orthostatic event, responding safely, and reporting it are squarely within scope and are exactly what the exam rewards.