Documentation in Geriatric Practice Flashcards
What is the primary purpose of documentation in geriatric practice?
A) To track billing for the client
B) To communicate with other professionals and ensure continuity of care
C) To keep a record of the therapist’s schedule
D) To monitor family involvement
B) To communicate with other professionals and ensure continuity of care
Which assessment tool is commonly used in geriatric documentation to evaluate functional mobility?
A) Barthel Index
B) Section GG coding
C) Montreal Cognitive Assessment (MoCA)
D) Katz Index
B) Section GG coding
Why is it important for OTs to distinguish between medical and treatment diagnoses in documentation?
A) To ensure accurate insurance reimbursement
B) To highlight the client’s medical history
C) To avoid duplication of services
D) To comply with HIPAA regulations
A) To ensure accurate insurance reimbursement
Which clinical documentation error could lead to a denial of therapy services in a geriatric setting?
A) Incomplete GG coding for functional independence
B) Failure to include a diagnosis code
C) Documenting an improvement in patient mobility
D) Excessive use of CPT codes
A) Incomplete GG coding for functional independence
What is the clinical importance of using the COAST method in documentation?
A) It ensures goal-setting is specific and measurable
B) It increases the likelihood of reimbursement
C) It enhances client engagement
D) It is required by insurance companies
A) It ensures goal-setting is specific and measurable
In which clinical situation would Section GG coding be used by an OT?
A) Assessing progress in functional mobility for a stroke patient in a skilled nursing facility
B) Documenting medication adherence in a home health setting
C) Evaluating a patient’s diet in a long-term care facility
D) Tracking social interaction in outpatient therapy
A) Assessing progress in functional mobility for a stroke patient in a skilled nursing facility
Which key aspect is essential for Medicare reimbursement in therapy documentation?
A) Accurate time spent with the client
B) Use of client-centered goals and skilled intervention
C) Reporting dietary intake at every session
D) Tracking family involvement
B) Use of client-centered goals and skilled intervention
What should be documented if an elderly client shows a functional decline during therapy?
A) Justification for continuation of skilled therapy services
B) A referral to another healthcare professional
C) Immediate discharge planning
D) A decrease in therapy intensity
A) Justification for continuation of skilled therapy services
How does Section GG coding impact the overall treatment plan in geriatric care?
A) It informs care goals and discharge planning
B) It determines billing codes for therapy
C) It replaces traditional outcome measures
D) It tracks family involvement in care
A) It informs care goals and discharge planning
Which documentation method is used to outline long-term goals in geriatric practice?
A) Narrative documentation
B) SOAP note format
C) COAST goal method
D) ICD-10 coding
C) COAST goal method
Why is Section GG coding critical in post-acute care settings?
A) It tracks billing compliance
B) It standardizes functional assessment for clients
C) It is used only for documenting diagnosis
D) It is optional for therapists
B) It standardizes functional assessment for clients
In documenting the Plan of Care (POC), which element is most important for geriatric patients?
A) The family’s wishes
B) The patient’s current level of function and potential for improvement
C) The medical diagnosis
D) The type of insurance coverage
B) The patient’s current level of function and potential for improvement
Which billing code is typically used for low complexity occupational therapy evaluations in geriatric settings?
A) CPT Code 97161
B) CPT Code 97162
C) CPT Code 97163
D) CPT Code 97535
A) CPT Code 97161
What is the role of documentation in justifying the need for skilled occupational therapy services?
A) To ensure timely discharge of the client
B) To provide evidence of progress and skilled intervention
C) To track the therapist’s schedule
D) To manage equipment orders
B) To provide evidence of progress and skilled intervention
Why must OTs document specific functional deficits in geriatric practice?
A) To comply with Medicare and other payer requirements
B) To avoid client lawsuits
C) To track billing
D) To maintain a record of family involvement
A) To comply with Medicare and other payer requirements
In geriatric documentation, which method is most commonly used to evaluate patient improvement in activities of daily living (ADLs)?
A) Section GG coding
B) Patient Health Questionnaire (PHQ-9)
C) Montreal Cognitive Assessment (MoCA)
D) Timed Up and Go (TUG)
A) Section GG coding
