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P.D. II > Documentation > Flashcards

Documentation Flashcards

1
Q

HIPAA

A

Heath Insurance Portability and Accountability Act. Includes the Privacy Rule

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2
Q

Privacy Rule

A

Allows health care providers to share information regarding their clients yet still protect this sensitive information from the general public

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3
Q

SOAP notes

A

Used for communicating daily or weekly information within facilities.

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4
Q

“S” in SOAP note stands for what?

A

Subjective- what has been said by the pt

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5
Q

“O” in SOAP note stands for what?

A

Objective- observable and measurable data from evaluation and treatment results

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6
Q

“A” in SOAP note stands for what?

A

Assessment- Opinion, interpretation or assessment of the results of client’s functional performance and anticipated outcomes including problem list and long- and short-term goals

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7
Q

“P” in SOAP note stands for what?

A

Plan- the treatment plan including frequency and duration of treatment

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8
Q

Less structured than SOAP notes, these can be used to document client contact that is not necessarily during treatment

A

narrative notes

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9
Q

Level of assistance when pt requires no assistance or cueing in any situation and is trusted in all situations 100%

A

independent

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10
Q

Level of assistance when caregiver is not required to provide any hands-on guarding but may need to give verbal cues for safety

A

supervision

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11
Q

Level of assistance when caregiver must provide hands-on contact guard to be within arm’s length for client’s safety

A

contact guard/standby

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12
Q

Level of assistance when caregiver provides 25% physical and/or cueing assistance

A

Minimum assistance

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13
Q

Level of assistance when caregiver assists client with 50% of the task

A

Moderate assistance

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14
Q

Level of assistance when caregiver assists client with 75% of the task

A

Maximum assistance

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15
Q

Level of assistance when client is unable to assist in any part of the task

A

dependent (Total assist-TA)

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16
Q

Form of documentation that is typically in the form of a grid

A

flow sheet

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17
Q

Four main components of functional outcomes

A
  1. Must Address performance
  2. Must have measurable data to indicate when outcome has been met
  3. Needs to specify specific conditions under which the performance should be completed
  4. Needs to give a time frame for completion
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18
Q

What is the 8-step process of clinical reasoning for documentation?

A
  1. After referral to OT and eval, predict functional outcomes on the basis of groups of people with similar problems
  2. Consider the client, present and past functional abilities, and occupational history. Collaborate with the client on activities that are meaningful and achievable. Set client outcomes.
  3. Observe performance
  4. Establish a sequence for short term objectives
  5. Consider the timing of outcomes and short-term objectives, and prioritize and sequence treatment methods
  6. Reassess performance and complete daily and/or weekly notes
  7. Reexamine outcomes and short-term objectives, and complete the monthly summary
  8. Complete discharge summary
19
Q

Initial evaluation report is divided into what 4 sections?

A
  1. Description of the ct’s occupational PROFILE
  2. Analysis of the ct’s occupational PERFORMANCE
  3. PRIORITIZING areas of occupation and occupational performance
  4. Intervention PLAN
20
Q

Daily notes

A

Brief and reflect the treatment provided, the client’s response to treatment, and progress noted

21
Q

Progress notes

A

required on a weekly or biweekly basis.

22
Q

This describes the client’s final status on discharge from the facility

A

discharge summary

23
Q

This pays for hospital inpatient, SNF, home, and hospice care

A

Medicare part A

24
Q

This pays for hospital outpatient, physician, and other professional services

A

Medicare part B

25
Q

Ways to measure changes in patient’s therapy

A
  • frequency/consistency
  • duration
  • assistance
  • quality of performance
  • level of complexity
26
Q

OBRA

A

Omnibus Budget Reconciliation Act

27
Q

RAI

A

Resident Assessment Instrument

28
Q

PPS

A

Prospective Payment System

29
Q

MCA/ MCB

A

Medicare A/Medicare B

30
Q

MA

A

Medicaid

31
Q

OAA

A

Older Americans Act

32
Q

RUG

A

Resource Utilization Group

33
Q

What is the purpose of RUG?

A

It decides the intensity of care. You will see more or less of the pt

34
Q

OP

A

outpatient

35
Q

HH

A

Home health

36
Q

In SNF, Part B covers after _____ days of MCA

A

100

37
Q

MCB only covers ____% of charges. Client or coinsurance covers ____%

A

80, 20

38
Q

CPT codes

A

Current procedural terminology codes

39
Q

MCA eligibility in SNF

A 
3 day hospital stay
daily to 3x/wk services req
inpatient
MD order
Necessary, reasonable frequency/duration
40
Q

Comprehensive HH assessment and outcome measure

A

OASIS

41
Q

This requires elder be homebound in HH for reimbursement

A

MCA

42
Q

This Act assists elders in remaining in their homes and communities. Goal is to increase I

A

Older Americans Act (OAA)

43
Q

This Act encouraged community-based alternatives for people with disabilities

A

Olmstead Act

44
Q

HHS

A

Health and Human Services

P.D. II (9 decks)

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