Chapter 17

Question 1

The medical record is a ______ record

Answer 1

Legal

Question 2

Everyone who provides pt svcs and records info may be held accountable for the quality of tx rcvd based on what?

Answer 2

Documentation

Question 3

In these tips of records, each source or clinical discipline such as nursing or OT, documents info in a separate section of the chart

Answer 3

Source oriented and integrated records

Question 4

In this type of record, The notes are organized into smaller sections, each for a different discipline

Answer 4

Source oriented

Question 5

In this record, all the notes from different disciplines are in one section

Answer 5

Integrated record

Question 6

Because of problems with source oriented and integrated records, like chronological documentation this type of record came about

Answer 6

Problem oriented

Question 7

Who came up with the problem oriented medical record?

Answer 7

Lawrence Weed

Question 8

POMR

Answer 8

Problem oriented med record

Question 9

The POMR is organized into three major sections. What are they?

Answer 9

Database
Problem list
Reports of plans and progress

Question 10

This part of the POMR is developed in the first 48 hours of hospitalization or outpt tx. It contains the same info as what might be included in the admission report.

Answer 10

database

Question 11

This part of the POMR is developed from the database. It identifies all of the pt’s problems.

Answer 11

problem list

Question 12

This section of the the POMR discusses reports of plans and progress

Answer 12

Reports of plans and progress

Question 13

____________ reports identify the assessments that were used, the results of these assessments, the therapist’s interpretation of the results, and the therapist’s tx plan

Answer 13

Eval

Question 14

The __________ plan spells out the goals established, the methods to be used, the frequency of tx, and the time by which the therapist expects the goals to be reached.

Answer 14

Intervention

Question 15

A _______________________ documents individual OT sessions or contacts and the service provided.

Answer 15

contact, tx, or visit note

Question 16

A ______ report documents tx periodically, updating info on progress toward functional goals, changes to the plan, and coordination of care.

Answer 16

progress

Question 17

A __________ report documents the results of the reevaluation, compares these to the initial eval, and recommends changes or continuations in the plan.

Answer 17

reevaluation

Question 18

A _________ plan is written in preparation for a move from one setting to another

Answer 18

transition

Question 19

A ___________ report gives a concise description of the entire course of OT intervention since first contact and includes assessment of outcomes

Answer 19

discharge or discontinuation

Question 20

This type of report documents the facts of an emergency in which, for example, a pt was injured or eloped while under the supervision of an OT staff member.

Answer 20

critical incident report

Question 21

Two other letters a COTA may write include _.

Answer 21

appeal letter and letter of advocacy (to speak on behalf of pt, group, or population)

Question 22

The COTA keeps records on each tx service he or she provides. Sometimes this is referred to as a ____________ (think of trees).

Answer 22

therapy log