Ch 8: Documentation Vocab

Question 0

Skilled Services

Answer 0

Requires services of professional training in the field of OT

Question 1

Progress Report

Answer 1

Document that expresses progress towards goal achievement

Question 2

Skilled Interventions

Answer 2

Involve the use of therapeutic use of self, occupation based activities and client, caregiver education…

Question 3

Confidentiality

Answer 3

Protection of info that can appear in all forms of communications

Question 4

Reimbursement

Answer 4

Regulations and requirements set up by a major payer source for the geriatric population

Question 5

Long-Term Goal (LTG)

Answer 5

Overall functional outcome of the OT process

Question 6

Clinical/professional Reasoning

Answer 6

Process used by OT practitioner to plan, direct, perform, and reflect on client care

Question 7

Discharge Report

Answer 7

Written at conclusion of therapy program

Question 8

Ethical Practice

Answer 8

Includes the 7 principles defined by AOTA to direct the OT practitioner in expected behaviors and expectations

Question 9

Evaluation

Answer 9

Foundation upon which all components of client program are identified

Question 10

Occupational Profile

Answer 10

Contains info gathered during an interview process

Question 11

Assessments

Answer 11

Standardized/Nonstandardized ways of measuring and establish a baseline

Question 12

Medical Record

Answer 12

Contains personal data and info relevant to the treatment of a patient, client, or person receiving medical treatment

Question 13

Documentation

Answer 13

Necessary part of the OT process. Promotes professionalism and proof of value of intervention

Question 14

Medicare Guidelines

Answer 14

Payments for OT services according to specific regulations and requirements

Question 15

Short-Term Goal (STG)

Answer 15

Written for specific time frame and are specific to the accomplishment of the long term goal

Question 16

OTPF-2

Answer 16

Occupational Therapy Practice Framework-2

Question 17

Legal Document

Answer 17

Documentation that follows guidelines that will allow it to stand up in a legal investigation

Question 18

HIPAA

Answer 18

Federal laws enacted to protect the consumer from breaches of confidentiality

Question 19

Intervention Plan

Answer 19

Collaborative effort designed to establish goals and functional outcomes

Question 20

SOAP notes

Answer 20

Subjective:what client tells you
Objective:fact info that is observed or measurable
Assessment:analyze and adjust
Plan:what to do next

Question 21

SMART

Answer 21

Significant
Measurable
Achieve
Relate
Time-limited

Question 22

RUMBA

Answer 22

Relevant 
Understandable
Measurable
Behaviorable
Achievable