Doc Final Flashcards
Why is documentation important in Occupational Therapy? Name at least two reasons.
Accurate record keeping, information and feedback, to show our distinct value.
Please write out what the acronym SOAP stands for.
S - subjective
O - objective
A - assessment
P - plan
Name two different examples of legislation that impact Health Care and Documentation.
HIPAA, FERPA, HITECH, ACA, FDASIA, the IMPACT Act, IDEA
The purpose of the health record is to…
a. provide a legal document
b. exchange information between health care providers
c. be utilized for reimbursement purposes
d. all of the above
d. all of the above
provide a legal document, exchange information between health care providers, be utilized for reimbursement purposes
A health professional’s clinical judgement and interpretation of the statements and events reported during the treatment session is documented under the following:
a. Subjective
b. Objective
c. Assessment
d. Plan
c. Assessment
Performance skills include…
a. the COTA examining and documenting how tasks are performed and what factors may impede function
b. physical, social, and virtual environments
c. the COTA reviewing the importance of activities of daily living, health management, and social participation
d. documenting the skilled need of Occupational Therapy
a. the COTA examining and documenting how tasks are performed and what factors may impede function
What is the difference between an Occupational Therapist and Occupational Therapy Assistant?
The OT is known as a therapist or clinician. They write the POC, set and change goals, delegate goals, authorize a d/c.
The OTA performs treatment based on the OT’s POC with duties delegated by the supervising OT, communicate with the OT, complete documentation within state laws, recommend patient for d/c.
This document is written at the end of a specified period of time.
a. initial evaluation
b. progress note
c. transition plan
d. contact note
b. progress note
Name three uses of the health record.
Client care management, reimbursement, the legal system, research/EBP, accrediation, education, public health, business development, the client, clinical quality measures.
An example of a physical environment would be…
a. internet access
b. video chat
c. church community
d. elementary school
d. elementary school
Which of the following is true about abbreviations?
a. Abbreviations cannot be easily confused.
b. Approved abbreviations vary from facility to facility.
c. The use of abbreviations is not common.
d. The use of abbreviations will lengthen your documentation time.
b. Approved abbreviations vary from facility to facility.
What are three functions a therapy tech/aide is able to complete?
…photocopying, assisting in putting paperwork in charts, maintenance, preparing areas for tx, transporting patients, assisting the practitioner with a group or during a transfer.
Spelling, grammar and errors will make practitioners question your credibility, your credentials, your competence or intelligence.
True
False
True
Please match the following medical terms with the correct abbrevations.
abduction
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
D. abd
Please match the following medical terms with the correct abbrevations.
adduction
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
A. add
Please match the following medical terms with the correct abbrevations.
basic activities of daily living
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
C. BADLs
Please match the following medical terms with the correct abbrevations.
Certified Occupational Therapy Assistant
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
F. COTA
Please match the following medical terms with the correct abbreviation.
hypertension
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
E. HTN
Please match the following medical terms with the correct abbreviation.
out of bed
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
J. OOB
Please match the following medical terms with the correct abbreviation.
follow up
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
H. F/U
Please match the following medical terms with the correct abbreviation.
physical agent modaility
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
G. PAM
Please match the following medical terms with the correct abbreviation.
plan of care
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
B. POC
Please match the following medical terms with the correct abbreviation.
vital signs
All Answer Choices A. add B. POC C. BADLs D. abd E. HTN F. COTA G. PAM H. F/U I. VS J. OOB
I. VS
What is the difference between a skilled Occupational Therapy service and an unskilled service?
◦Skilled services: specific criteria and performed by qualified professionals. Require professional education, decision-making, and highly complex competencies.
◦Nonskilled services: routine or maintenance that can be carried out by nonprofessionals or caregivers.
◦Documentation to justify:
◦Potential for functional improvement
◦Equipment recommendations, training, est. maintenance program
◦Specific medical need requiring expertise of OT
Academic degrees and professional designations after a person’s name need to be capitalized.
True
False
true
Fraud is…
a. Willfully making false statements in order to obtain some benefit.
b. Ability to govern onself through the use of reason.
c. Indirect practices that result in unnecessary costs to Medicare.
d. Promotion of equity, inclusion, and objectivity in the provision of OT services.
a. Willfully making false statements in order to obtain some benefit.
What is the difference between directly quoting someone and paraphrasing someone in a note?
- Quotations: used when you are using exact words from a patient
- Paraphrasing: used to summarize what a patient says
An Occupational Therapy Practitioner assists clients with their ADLs.
True
False
false
Verb tenses can switch throughout a note.
True
False
false
Which of the following are funding sources for Occupational Therapy services?
a. Medicare
b. Medicaid
c. Worker’s Compensation
d. All of the above
d. All of the above
Medicare, Medicaid, Worker’s Compensation
What information is included in the “Subjective” portion of the note?
- Expresses client’s perspective on his/her condition or treatment
- Can include c/o pain and fatigue; use pain scale accordingly
- Has more significance and relevance to the rest of the note
- Specifically pinpoints an issue than a vague comment
- If the client is unable to speak, or make relearn comments, include that in the note
- Caregivers and family may provide specific “S” information
- Effective communication will help direct tx and identify strengths/deficits
- Paraphrasing can be used to make the note more concise.
List 2 ways the content of the “O” section of a SOAP note can be organized.
chronologic
catigoric
Name three qualities of the information recorded in the “O” section of a SOAP note.
○ Observable
○ Measurable
○ Quantifiable
Discuss why avoiding duplication of services in your notes is important.
Fraud is illegal and can cause you to lose your license
Remember that the ________ in the “P” section should be consistent with those established in the OT’s intervention plan.
a. performance skills
b. time frames
c. client factors
d. level of assist
b. time frames
Which of the following are TRUE regarding the Assessment section?
a. It is important to include new information in this section.
b. It is important to include direct patient quotes in this section.
c. It is important that the information in the “A” is supported by information also in the “S” and “O” section.
d. It is important to include the duration of treatment in this section.
c. It is important that the information in the “A” is supported by information also in the “S” and “O” section.
Name the three P’s that are discussed in the A section.
problems, progress, potential
The Assessment section consists of the OTP’s skilled appraisal.
True
False
True
Name two things found in the P section.
specific intervetions that will be utilized going forward, required follow up, recommendations provided to client/family, goals, rehabilitation potential, duration and frequency of continued treatments, etc…
Consider the following “special situation” and indicate the category:
Resident did not arrive for scheduled OT session. Called nurse’s station and RN stated resident wasn’t feeling well this morning and was sleeping. Will attempt to see resident again this afternoon.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• No-Shows
Consider the following “special situation” and indicate the category:
Child became angry when told he must stay seated in his chair. He then yelled several profane words and bit COTA’s hand. Child was then sent to principal’s office to address inappropriate behavior.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• Incidents
Consider the following “special situation” and indicate the category:
Client did not show up for appointment. Called client’s house and he stated he could not get his car started. Rescheduled for Saturday.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• No-Shows
Consider the following “special situation” and indicate the category:
Child seen in dining room for instruction in feeding skills. Five minutes into session, the physician came to take child for medical evaluation. Will attempt OT session again tomorrow for further skilled instruction in feeding.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• Treatment Interruptions
Consider the following “special situation” and indicate the category:
Attempted to see patient today, but patient was unavailable due to dialysis. Will attempt to see patient again tomorrow.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• Medical Hold
Consider the following “special situation” and indicate the category:
Client sustained small cut to left pinky finger distal phalanx while cutting vegetables in cooking group. Wound cleaned and bandage applied. Nursing notified.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• Incidents
Consider the following “special situation” and indicate the category:
Nursing requested that OT be deferred today due to side effects pt is experiencing from chemotherapy, such as extreme fatigue, nausea, vomiting.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• Medical hold
Consider the following “special situation” and indicate the category:
Upon arrival to OT clinic, resident stated she needed to have a bowel movement. Resident was transported back to her room and nursing staff was notified.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• Treatment Interruptions
Consider the following “special situation” and indicate the category:
Client called to reschedule OT appointment due to feeling dizzy and not being able to drive. Appointment rescheduled for tomorrow.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• No-Shows
Consider the following “special situation” and indicate the category:
Patient called to report he was hospitalized for two nights secondary to pneumonia. OT deferred until MD’s orders are received to resume.
- No-Shows
- Treatment Interruptions
- Medical Hold
- Incidents
- Phone Calls
- Photos and Videos
• Medical Hold
It is important to include the date and time when documenting pertinent phone calls regarding a patient or client.
yes
Effective documentation does not require that you hone your observation skills to increase accuracy.
true
false
false
It is important to note what the client did before your OT treatment.
true
false
false
Which of the following is a reason to discontinue occupational therapy?
a. Client expired
b. Physician discontinued therapy
c. Client not making progress
d. No further skilled OT is medically or educationally necessary
e. All of the above
e. All of the above
Which type of note/report completed on a regularly scheduled basis summarizes the intervention process and documents the patient’s progress toward achievement of goals?
a. Contact
b. Progress
c. Discharge
d. Reevaluation
b. Progress
Which of the following is true of Long-Term Goals?
a. They should include sub-steps.
b. They should include an accurate GG code.
c. The timeframe may vary between client’s and settings based on the condition of the client.
d. There should be several goals for each step.
c. The timeframe may vary between client’s and settings based on the condition of the client.
Which of the following is not information typically reported in a progress note?
a. Client’s name, date of birth, gender, diagnosis, precautions
b. Summary of services provided including brief statement of frequency, summary of techniques/strategies used, and equipment issued to the patient
c. Client’s progress toward the goals and client’s performance in areas of occupation
d. Reasons for discontinuing occupational therapy services
d. Reasons for discontinuing occupational therapy services
Which type of note/report should summarize new information about a patient and include updates on issues, changes, abilities, or concerns that relate to the occupational profile and is the primary responsibility of the OT?
a. Contact
b. Progress
c. Discharge
d. Reevaluation
d. Reevaluation
Goals must include the following:
Selected all that apply:
a. Problems, progress, potential.
b. Functional, measureable, action-oriented items.
c. Achievable timelines.
d. GG codes.
e. Achievable timelines.
b. Functional, measureable, action-oriented items.
c. Achievable timelines.
d. GG codes.
e. Achievable timelines.
The client is able to complete LB dressing with 45% assistance from the helper. Which of the following assist levels/GG codes would accurately describe their level of assist required?
a. Supervision or Touching Assistance
b. Partial/Moderate Assistance
c. Substantial/Maximum Assistance
d. Dependent
b. Partial/Moderate Assistance
A goal may be written to address what a parent or caregiver will achieve with skilled instruction from an OTP.
True
False
true
Match the setting with the most applicable/appropriate type of documentation or documentation concern.
School-Based Practice
A. Length of stay is generally brief, so formal reevaluation reports are rarely needed. Contact notes are written after each treatment session to communicate therapeutic interventions, progress or changes in client’s condition, and current functional status.
B. Individualized Education Program (IEP)
C. Therapy logs are used to keep track of day-to-day interventions and progress notes are completed at regular intervals.
D. Documentation focused on client’s progress, functional improvement, and intervention focused on returning client’s safe return home or to a community-based environment upon discharge. Contact notes are used after each treatment session.
E. Outcome and Assessment Information Set data collection method is used.
F. Uses a family-centered plan that contains specific information about the child’s developmental status, family situation, and assessment results. It designates a service coordinator for the child’s care.
B. Individualized Education Program (IEP)
Match the setting with the most applicable/appropriate type of documentation or documentation concern.
Early Intervention
A. Length of stay is generally brief, so formal reevaluation reports are rarely needed. Contact notes are written after each treatment session to communicate therapeutic interventions, progress or changes in client’s condition, and current functional status.
B. Individualized Education Program (IEP)
C. Therapy logs are used to keep track of day-to-day interventions and progress notes are completed at regular intervals.
D. Documentation focused on client’s progress, functional improvement, and intervention focused on returning client’s safe return home or to a community-based environment upon discharge. Contact notes are used after each treatment session.
E. Outcome and Assessment Information Set data collection method is used.
F. Uses a family-centered plan that contains specific information about the child’s developmental status, family situation, and assessment results. It designates a service coordinator for the child’s care.
F. Uses a family-centered plan that contains specific information about the child’s developmental status, family situation, and assessment results. It designates a service coordinator for the child’s care.
Match the setting with the most applicable/appropriate type of documentation or documentation concern.
Acute Care
A. Length of stay is generally brief, so formal reevaluation reports are rarely needed. Contact notes are written after each treatment session to communicate therapeutic interventions, progress or changes in client’s condition, and current functional status.
B. Individualized Education Program (IEP)
C. Therapy logs are used to keep track of day-to-day interventions and progress notes are completed at regular intervals.
D. Documentation focused on client’s progress, functional improvement, and intervention focused on returning client’s safe return home or to a community-based environment upon discharge. Contact notes are used after each treatment session.
E. Outcome and Assessment Information Set data collection method is used.
F. Uses a family-centered plan that contains specific information about the child’s developmental status, family situation, and assessment results. It designates a service coordinator for the child’s care.
A. Length of stay is generally brief, so formal reevaluation reports are rarely needed. Contact notes are written after each treatment session to communicate therapeutic interventions, progress or changes in client’s condition, and current functional status.
Match the setting with the most applicable/appropriate type of documentation or documentation concern.
Inpatient Rehabilitation Facilities
A. Length of stay is generally brief, so formal reevaluation reports are rarely needed. Contact notes are written after each treatment session to communicate therapeutic interventions, progress or changes in client’s condition, and current functional status.
B. Individualized Education Program (IEP)
C. Therapy logs are used to keep track of day-to-day interventions and progress notes are completed at regular intervals.
D. Documentation focused on client’s progress, functional improvement, and intervention focused on returning client’s safe return home or to a community-based environment upon discharge. Contact notes are used after each treatment session.
E. Outcome and Assessment Information Set data collection method is used.
F. Uses a family-centered plan that contains specific information about the child’s developmental status, family situation, and assessment results. It designates a service coordinator for the child’s care.
D. Documentation focused on client’s progress, functional improvement, and intervention focused on returning client’s safe return home or to a community-based environment upon discharge. Contact notes are used after each treatment session.
Match the setting with the most applicable/appropriate type of documentation or documentation concern.
Skilled Nursing Facilities
A. Length of stay is generally brief, so formal reevaluation reports are rarely needed. Contact notes are written after each treatment session to communicate therapeutic interventions, progress or changes in client’s condition, and current functional status.
B. Individualized Education Program (IEP)
C. Therapy logs are used to keep track of day-to-day interventions and progress notes are completed at regular intervals.
D. Documentation focused on client’s progress, functional improvement, and intervention focused on returning client’s safe return home or to a community-based environment upon discharge. Contact notes are used after each treatment session.
E. Outcome and Assessment Information Set data collection method is used.
F. Uses a family-centered plan that contains specific information about the child’s developmental status, family situation, and assessment results. It designates a service coordinator for the child’s care.
C. Therapy logs are used to keep track of day-to-day interventions and progress notes are completed at regular intervals.
Match the setting with the most applicable/appropriate type of documentation or documentation concern.
Home Health
A. Length of stay is generally brief, so formal reevaluation reports are rarely needed. Contact notes are written after each treatment session to communicate therapeutic interventions, progress or changes in client’s condition, and current functional status.
B. Individualized Education Program (IEP)
C. Therapy logs are used to keep track of day-to-day interventions and progress notes are completed at regular intervals.
D. Documentation focused on client’s progress, functional improvement, and intervention focused on returning client’s safe return home or to a community-based environment upon discharge. Contact notes are used after each treatment session.
E. Outcome and Assessment Information Set data collection method is used.
F. Uses a family-centered plan that contains specific information about the child’s developmental status, family situation, and assessment results. It designates a service coordinator for the child’s care.
E. Outcome and Assessment Information Set data collection method is used.
Which of the following is included under the “S” of a COAST goal?
a. Under what conditions?
b. Subjective.
c. By when?
d. Short-term goal.
a. Under what conditions?
Which type of note/report would be used to document a hands-on caregiver training session between a COTA, a patient, and the patient’s caregiver?
a. Contact
b. Progress
c. Discharge
d. Reevaluation
a. Contact
Which type of note/report would be used to document a typical intervention session with a patient?
a. Contact
b. Progress
c. Discharge
e. Reevaluation
a. Contact
What does COAST stand for?
○ C - Client ○ O - Occupation ○ A - Assist level ○ S - Specific condition ○ T - Timeline
What is the “C” for Coast for
• C - Client
○ Must be main focus; do NOT indicate what OTA will do
§ Use appropriate verb (eg demo, complete, preform)
§ Client will perform
What is the “O” for Coast for
• O - Occupations
○ Goals must pertain to and specify occupation and directly relate to a problem identifies in OT intervention plan
What is the “A” for Coast for
• A - assist level
○ Delineates expected level of assistance the client will achieve when performing the specified occupation; includes quantifiable physical
What is the “S” for Coast for
• S - specific condition
○ Additional criteria or conditions under which client is expected to perform the desired action (a compensatory technique, use of durable medical equipment/adaptive equipment, client position, location)
○ You don’t always need an A or S, but you must have one.
What is the “T” for Coast for
• T - timeline
Time frame within which the goal is expected to be accomplished
