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Documentation > Doc Exam 2 > Flashcards

Doc Exam 2 Flashcards

1
Q

Suggestion, No federal rules

A

Referrals

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2
Q

Referrals are received based on

A

State licensure and payor policy

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3
Q

When to refer to others

A

Outside of our knowledge base, personal issues, others w/ expertise

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4
Q

AOTA prefers term

A

physician referral

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5
Q

Substitute for order
Can be specific or very broad

A

Care plans/treatment plan

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6
Q

Medicare requires recertification every

A

30 days for outpatient (60 for homecare)

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7
Q

Referral includes

A

Full name/client
Date
Reason for referral (dx)
Full name and physician signature
Frequency/duration (can include intensity/length of session)

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8
Q

brief check to see if client needs further eval, referral, or intervention
Not reimbursable
Can be done without physician order/referral

A

Screenings

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9
Q

routinely screening individuals in a particular setting

A

Type 1 screen

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10
Q

screening after referral has been received

A

Type 2 screen

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11
Q

Screen CAN/CANNOT be subbed for an eval?

A

Cannot

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12
Q

Screen CAN/CANNOT be a component of eval??

A

Can

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13
Q

Guidelines of screening system:

A

Within scope
Timely
Understanding of population
Intervention should be available
Valid/reliable methods (does not mean standardized)

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14
Q

4 Possible outcomes of screen:

A
  1. Needs OT
  2. not severe enough to warrant OT
  3. Out of scope
  4. Doesn’t need anything
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15
Q

In screenings a COTA can…

A

Assist and report recommendations

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16
Q

brief note in the medical record

May be used to document….
Order/referral received
Screen was performed
Communication between OT and COTA
Recommendation for equipment
Recommendation of family or caregiver or training
Missed visits

A

Contact note

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17
Q

most impairment doc to OT; client centered and evidence based
All other documents/actions follow
Must show need for OT services; “medically necessity” “educationally relevant”
Must demonstrate the clients function presently and previously (prior to intervention)

A

Evaluation

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18
Q

process

A

Evaluation

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19
Q

Tool

A

Assessment

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20
Q

Describe current level, predict future function, measure for baseline

A

Evaluation

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21
Q

T/F: You do not have to provide intervention but you do have to apply evaluation

A

True

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22
Q

Examples of how an eval should describe any unique circumstances:

A

Previous injury, Context, Emotional issues, Inconsistency

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23
Q

performance first

Kolhman, TOGGS, school functional assessment, ADL

A

Top down eval

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24
Q

client factors first

Berg, DTVP3, ROM, MMT, ACL
Frame of reference must go w/ eval

A

Bottom up eval

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25
Q

ID info (Dx, name, age)
Reason for referral
Referral source
Previous tools/test
Precautions/contraindications
Appropriate dx?
Occupational profile
How results affect occupational performance
Consistency b/w results and behavior

A

Components of Eval

26
Q

looks @ everything

A

Comprehensive eval

27
Q

Example of Problem specific eval

A

DASH, ADL assessment

28
Q

Example of standardized eval

A

peabody

29
Q

Not standardized eval

A

reflexes, clinical experience/observation

30
Q

Informal eval

A

cognition interaction, orientation

31
Q

Activity based eval example

A

ACL, FCE

32
Q

Things to consider in evaluations

A

Personal development
Context
Relationship
Occupational performance
Development and occupational relationships

33
Q

Things to remember in evaluations

A

Ongoing and dynamic
Bias, expectations, and prejudices
Client/family perspective
Completed eval should depict client well

34
Q

responsible for the process

Choosing appropriate eval

Summarizing, analyzing and interpreting

Developing the intervention plan

Referring to another party or profession

writes the Plan

A

OTR role

35
Q

can contribute, perform parts or components

Give input

A

COTA role

36
Q

This role can Educate and explain evaluation to family or client

A

Both COTA and OTR

37
Q

Paves the way to justify your plan
Show OT as necessary

A

How you report and interpret

38
Q

constant

Informal or formal

A

Re-eval

39
Q

every time you see the client
May result in changes to care plan or treatment
Don’t charge

A

Informal re-eval

40
Q

depends on payer and facility and you
May result in changes or show progress and justify continuation
Can usually charge
Facility, payor source, protocol of test, doc visit, major change, adding goals

A

Formal re-eval

41
Q

May or may not include the goals
Describes what is going to happen during the therapy process
Collaboration between: OTR, COTA, Client

A

Intervention Plans
Treatment plans

42
Q

Medicare Criteria:

A

Must functionally improve
Reasonable time
Not maintenance
Not spontaneous

43
Q

The cota can change these but not the goals
The COTA may choose which ones (following accepted practice and protocol) to use on which days, but she/he can’t add or choose to delete items-only the OTR can do that

A

Activity

44
Q

Things to do when there’s no progress

A

Explain why: Barriers, What you have done about them
Explain the new plan ( if there is one) or discharge with recommendations
Should reflect: Individual, group , consult ect

45
Q

Goals must be

A

Measurable - Objective
Functional - This makes us OT
Achievable - Not too easy, Not too hard

46
Q

Guide the treatment interventions
Let us know when to discharge
Give a method for assessing the effectiveness of the intervention

A

Goals

47
Q

Goal Directions: How do we know what type to use?

A

Frame of reference you are using
Setting
OT Framework

48
Q

shoulder ROM will increase to 180° to be able to hang laundry

A

Biomechanical goal

49
Q

Pt will reach overhead to hang clothing without scapular elevation

A

NDT goal

50
Q

Pt will hang 10 pieces of laundry in 5min

A

Task oriented goal

51
Q

Types of goals

A

Restorative
Habilitative
Maintenance
Modification/Compensation/Adaptation
Preventive
Health Promotion

52
Q

Restore previous occupational performance

A

Restorative

53
Q

Teach new occupational performance skills

A

Habilitative

54
Q

Keep current occupational performance skills

A

Maintenance

55
Q

Change contexts or activity demands to enable occupational performance

A

Modification

56
Q

Prevent occupational performance deficits from developing

A

Preventive

57
Q

Enrich or enhance occupational performance skills

A

Health promotion

58
Q

Overarching
When to discharge
Discharge goals
Objectives

A

Long Term - LTG

59
Q

May change as the client progresses or fails to progress

A

STG - Specific time (days, weeks , visits)

60
Q

Formats

A

ABCD
COAST
RHUMBA
SMART

61
Q

How to make them measurable

A

Frequency or consistency
Duration
Assistance
Quality
Level of complexity
Participation
Others
Decrease in behaviors

Documentation (4 decks)

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