Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Documentation > Doc Exam 2 > Flashcards

Doc Exam 2 Flashcards

1
Q

Suggestion, No federal rules

A

Referrals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Referrals are received based on

A

State licensure and payor policy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

When to refer to others

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

AOTA prefers term

A

physician referral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Substitute for order
Can be specific or very broad

A

Care plans/treatment plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Medicare requires recertification every

A

30 days for outpatient (60 for homecare)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

routinely screening individuals in a particular setting

A

Type 1 screen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

screening after referral has been received

A

Type 2 screen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Screen CAN/CANNOT be subbed for an eval?

A

Cannot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Screen CAN/CANNOT be a component of eval??

A

Can

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Guidelines of screening system:

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

In screenings a COTA can…

A

Assist and report recommendations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

process

A

Evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Tool

A

Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Describe current level, predict future function, measure for baseline

A

Evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

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

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Examples of how an eval should describe any unique circumstances:

A

Previous injury, Context, Emotional issues, Inconsistency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

performance first

Kolhman, TOGGS, school functional assessment, ADL

A

Top down eval

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

client factors first

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

A

Bottom up eval

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
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
Components of Eval
26
looks @ everything
Comprehensive eval
27
Example of Problem specific eval
DASH, ADL assessment
28
Example of standardized eval
peabody
29
Not standardized eval
reflexes, clinical experience/observation
30
Informal eval
cognition interaction, orientation
31
Activity based eval example
ACL, FCE
32
Things to consider in evaluations
Personal development Context Relationship Occupational performance Development and occupational relationships
33
Things to remember in evaluations
Ongoing and dynamic Bias, expectations, and prejudices Client/family perspective Completed eval should depict client well
34
responsible for the process Choosing appropriate eval Summarizing, analyzing and interpreting Developing the intervention plan Referring to another party or profession writes the Plan
OTR role
35
can contribute, perform parts or components Give input
COTA role
36
This role can Educate and explain evaluation to family or client
Both COTA and OTR
37
Paves the way to justify your plan Show OT as necessary
How you report and interpret
38
constant Informal or formal
Re-eval
39
every time you see the client May result in changes to care plan or treatment Don’t charge
Informal re-eval
40
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
Formal re-eval
41
May or may not include the goals Describes what is going to happen during the therapy process Collaboration between: OTR, COTA, Client
Intervention Plans Treatment plans
42
Medicare Criteria:
Must functionally improve Reasonable time Not maintenance Not spontaneous
43
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
Activity
44
Things to do when there’s no progress
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
Goals must be
Measurable - Objective Functional - This makes us OT Achievable - Not too easy, Not too hard
46
Guide the treatment interventions Let us know when to discharge Give a method for assessing the effectiveness of the intervention
Goals
47
Goal Directions: How do we know what type to use?
Frame of reference you are using Setting OT Framework
48
shoulder ROM will increase to 180° to be able to hang laundry
Biomechanical goal
49
Pt will reach overhead to hang clothing without scapular elevation
NDT goal
50
Pt will hang 10 pieces of laundry in 5min
Task oriented goal
51
Types of goals
Restorative Habilitative Maintenance Modification/Compensation/Adaptation Preventive Health Promotion
52
Restore previous occupational performance
Restorative
53
Teach new occupational performance skills
Habilitative
54
Keep current occupational performance skills
Maintenance
55
Change contexts or activity demands to enable occupational performance
Modification
56
Prevent occupational performance deficits from developing
Preventive
57
Enrich or enhance occupational performance skills
Health promotion
58
Overarching When to discharge Discharge goals Objectives
Long Term - LTG
59
May change as the client progresses or fails to progress
STG - Specific time (days, weeks , visits)
60
Formats
ABCD COAST RHUMBA SMART
61
How to make them measurable
Frequency or consistency Duration Assistance Quality Level of complexity Participation Others Decrease in behaviors

Documentation (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions