Chapter 9: Documenting Outcomes Flashcards
What type of information is recorded in the ‘Subjective’ section of a SOAP note?
A. Observations and data collected
B. The OT’s professional judgment
C. Pertinent comments from the child, family, teacher, or others
D. Concise statements about the intervention plan
Answer: C. Pertinent comments from the child, family, teacher, or others
Which statement would be appropriate to include in the ‘Subjective’ section?
A. The child completed the task in 10 minutes.
B. The child stated they feel happy playing with their peers.
C. The therapist observed the child had difficulty grasping objects.
D. The intervention will focus on improving fine motor skills.
Answer: B. The child stated they feel happy playing with their peers.
Why is the ‘Subjective’ section important in a SOAP note?
A. It includes objective data and facts.
B. It provides context and relevant information from the child and others involved.
C. It contains the OT’s analysis and professional judgment.
D. It outlines the future plan of intervention.
Answer: B. It provides context and relevant information from the child and others involved.
What kind of information is included in the ‘Objective’ section of a SOAP note?
A. Therapist’s professional judgment
B. Pertinent comments from the child
C. Observations and other data collected; record of facts including strengths and limitations, as well as the location and reason the child is receiving services.
D. Future intervention plans
Answer: C. Observations and other data collected; record of facts including strengths and limitations, as well as the location and reason the child is receiving services.
Which of the following statements would be appropriate for the ‘Objective’ section?
A. The child feels anxious during playtime.
B. The child’s mother expressed concerns about his handwriting.
C. The child was able to cut out shapes with scissors independently.
D. The goal is to improve the child’s social interactions.
Answer: C. The child was able to cut out shapes with scissors independently.
What is the focus of the ‘Assessment’ section in a SOAP note?
A. Observations and collected data
B. Pertinent comments from the child or family
C. The OT’s professional judgment and therapeutic reasoning
D. The location and reason the child is receiving services
Answer: C. The OT’s professional judgment and therapeutic reasoning
Which statement would be appropriate for the ‘Assessment’ section?
A. The child said they enjoy drawing.
B. The child was able to complete the puzzle in 5 minutes.
C. The child demonstrates difficulty with fine motor tasks due to decreased hand strength.
D. The intervention will include activities to improve hand strength.
Answer: C. The child demonstrates difficulty with fine motor tasks due to decreased hand strength.
What should the ‘Assessment’ section convey about the information collected?
A. Only the child’s strengths
B. The OT’s professional judgment and therapeutic reasoning skills about the subjective and objective information
C. Comments from the child’s teacher
D. The specific activities planned for the next session
Answer: B. The OT’s professional judgment and therapeutic reasoning skills about the subjective and objective information
What is outlined in the ‘Plan’ section of a SOAP note?
A. The OT’s professional judgment
B. Observations and data collected
C. The plan to assist the child in meeting their goals
D. Subjective comments from the child or family
Answer: C. The plan to assist the child in meeting their goals
What is the purpose of the ‘Plan’ section in the SOAP format?
A. To record observations and collected data
B. To summarize the OT’s analysis and reasoning
C. To provide a Concise statement/s about the plan to assist the child in meeting their goals, including location, frequency, duration, intensity, and suggestions for intervention.
D. To document comments from the child’s family
Answer: C. To provide a concise statement/s about the plan to assist the child in meeting their goals, including location, frequency, duration, intensity, and suggestions for intervention.
List the Evaluation Process in order
A. Referral
B. Occupational profile
C. Gather data or background info
D. Formulate assessment plan
E. Administer assessment tool
F. Document results
G. Develop meaningful recommendations
H. Discharge
Answer:
A. Referral
B. Gather data or background info
C. Formulate assessment plan
D. Administer assessment tool
E. Document results
F. Develop meaningful recommendations
What type of documentation is created to detail the findings and recommendations following an initial assessment?
A. Intervention plan
B. Transition Plan
C. Re-evaluation report
D. Evaluation report
Answer: D. Evaluation report
Which of the following is NOT a type of documentation?
A. Screening report
B. Evaluation report
C. Re-evaluation report
D. Intervention plan (also called a Plan of Care)
E. Contact Report (also called a Daily
F. Treatment Note or Therapy Log)
G. Progress Note
H.Transition Plan
I. Occupational Profile
J. Discharge Report (also called a Discontinuation Report)
ANSWER:
I. Occupational Profile
