Ch. 8 Documentation Flashcards
What does SOAP stand for?
S-ubjective is reported by the client.
O-bjective is documented tests, assessments, observations, etc.
A-assessment is the interpreted data from subjective & objective
P-lan is the intervention plan to be performed
What does SMART stand for?
How S-ignificant is the goal?
Is it M-easurable?
Is it A-chievable?
Goals R-elate to one another & to client’s occupational needs
T-ime-limited: goals have an end point
What does FIM represent?
Functional Independence Measure
What does RHUMBA stand for?
How R-elevant is the information?
H-ow long will it take to accomplish goal?
How U-nderstandable is the info?
How M-easurable is the info?
Are B-ehaviors of the goal described?
How A-chievable is the outcome?FIM
What does level 7 represent?
Complete independence
FIM
What level are (timely) & (safely) on?
Level 7
FIM
What does level 6 represent?
Modified independence
FIM
What level is (device) on?
Level 6
FIM
What heading are levels 6 & 7 listed under?
No helper
FIM
What heading are levels 3, 4, & 5 listed under?
Helper- Modified Dependence
FIM
What does level 5 represent?
Supervision
FIM
What level is (subject = 100%) on?
Level 5
FIM
What does level 4 represent?
Minimal Assistance
FIM
What level is (subject = 75% or more) on?
Level 4
FIM
What does level 3 represent?
Moderate assistance
