National Physical Therapy Examination (NPTE) Practice Exam

When a patient refuses to participate in physical therapy, what is the most appropriate action for the physical therapist assistant to take?

1. Inform the physician who referred the patient for therapy treatment.

2. Communicate the event with the supervising therapist and schedule the patient with another staff member for a future visit.

3. Insist the patient participate in the therapy session.

4. Document the refusal in the medical record explaining the refusal.

The correct answer is: Document the refusal in the medical record explaining the refusal.

The most appropriate action when a patient refuses to participate in physical therapy is to document the refusal in the medical record, clearly explaining the circumstances surrounding the refusal. This documentation is essential for several reasons. Firstly, it serves as a formal record of the patient's decision, which is important for maintaining accurate medical records. Documentation protects both the patient and the healthcare provider by providing a clear account of patient autonomy in their care choices. It also ensures that anyone reviewing the patient's history in the future is aware of their refusal and the context of that decision. Secondly, documenting the refusal can help guide future interactions with the patient. If the patient is scheduled for follow-up care, knowing about their previous refusal will allow the supervising therapist and other staff members to approach the situation with sensitivity to the patient’s preferences and concerns. Though it may be necessary to inform other relevant parties, such as a supervising therapist, about the refusal, these steps typically follow the documentation, which is the immediate priority. Insisting a patient participate or scheduling them with another staff member without addressing the refusal might not respect the patient's autonomy and could lead to further patient disengagement. By focusing on the documentation aspect, you are ensuring that proper protocols are followed while reinforcing the importance of patient-centered care.