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
What does the “S” in a SOAP note represent in geriatric documentation?
A) Subjective
B) Solution
C) Summary
D) Significant finding
A) Subjective
Which ICD-10 code would be relevant for documenting a diagnosis of osteoarthritis in a geriatric patient?
A) M17.9
B) G30.9
C) F32.1
D) J44.9
A) M17.9
Why is Section GG coding important for goal setting in geriatric patients?
A) It helps track family involvement
B) It standardizes the assessment of functional abilities
C) It focuses on the patient’s medical diagnosis
D) It is primarily used for billing purposes
B) It standardizes the assessment of functional abilities
How should an OT document improvement in functional mobility for an elderly client?
A) By using standardized assessment tools such as Section GG coding
B) By reporting subjective observations
C) By tracking the client’s dietary habits
D) By recording family feedback
A) By using standardized assessment tools such as Section GG coding
What should be included in a discharge summary for a geriatric client?
A) Final functional status, summary of therapy goals, and recommendations for continued care
B) Insurance information and billing details
C) Client’s family background and preferences
D) A list of all interventions used during treatment
A) Final functional status, summary of therapy goals, and recommendations for continued care
In what situation should an OT use moderate complexity CPT evaluation codes (97162) in geriatric practice?
A) When a patient has 3-5 performance deficits and moderate medical complexity
B) When the client has no comorbidities
C) When only physical performance is assessed
D) When the evaluation is less than 30 minutes
A) When a patient has 3-5 performance deficits and moderate medical complexity
Which clinical tool is used in post-acute care settings to measure functional change over time?
A) Section GG coding
B) Mini Mental State Exam (MMSE)
C) Visual Analogue Scale (VAS)
D) Berg Balance Scale
A) Section GG coding
Why is detailed documentation of a geriatric client’s prior level of function critical?
A) It helps determine the goals and realistic outcomes of therapy
B) It provides information for the billing department
C) It simplifies discharge planning
D) It replaces the need for family input
A) It helps determine the goals and realistic outcomes of therapy
What is the primary purpose of the Plan of Care (POC) in geriatric documentation?
A) To outline the therapy goals and interventions for the patient
B) To track the number of therapy sessions completed
C) To inform the insurance company of the therapy costs
D) To document the patient’s family background
A) To outline the therapy goals and interventions for the patient
What is the Barthel Index primarily used to assess?
A) Cognitive function
B) Activities of daily living (ADLs)
C) Pain levels
D) Social participation
B) Activities of daily living (ADLs)
Which of the following tasks is NOT assessed in the Barthel Index?
A) Feeding
B) Bathing
C) Memory recall
D) Toilet use
C) Memory recall
What is the maximum score on the Barthel Index?
A) 50
B) 100
C) 200
D) 150
B) 100
Which patient population is the Barthel Index commonly used for?
A) Pediatric patients
B) Patients with musculoskeletal disorders
C) Patients with neurological conditions or stroke
D) Patients with mental health disorders
C) Patients with neurological conditions or stroke
What does Section GG coding assess?
A) Cognitive function
B) Mobility and self-care
C) Speech and language
D) Visual impairments
B) Mobility and self-care
How is Section GG typically scored?
A) From 0 to 10
B) Using a 6-point scale
C) From 1 to 100
D) Using a 10-point scale
B) Using a 6-point scale
What does a score of “06” indicate in Section GG coding?
A) Independent
B) Moderate assistance
C) Supervision or touching assistance
D) Dependent
A) Independent
Which of the following activities would be assessed using Section GG coding?
A) Feeding and grooming
B) Visual perception
C) Emotional regulation
D) Pain management
A) Feeding and grooming
The MoCA (Montreal Cognitive Assessment) is primarily used to screen for which condition?
A) Depression
B) Cognitive impairment
C) Physical mobility
D) Speech disorders
B) Cognitive impairment
What is the maximum score on the MoCA?
A) 20
B) 30
C) 40
D) 50
B) 30
Which of the following cognitive domains is NOT assessed by the MoCA?
A) Visuospatial abilities
B) Memory
C) Language
D) Muscle strength
D) Muscle strength
A score of 25 on the MoCA would most likely indicate:
A) Normal cognitive function
B) Mild cognitive impairment
C) Severe cognitive impairment
D) Dementia
B) Mild cognitive impairment
The Katz Index is used to assess:
A) Cognitive function
B) The independence in performing ADLs
C) Psychological health
D) Social participation
B) The independence in performing ADLs
Which of the following activities is assessed by the Katz Index?
A) Cooking
B) Bathing
C) Shopping
D) Community mobility
B) Bathing
What is the highest possible score on the Katz Index?
A) 4
B) 6
C) 10
D) 8
B) 6
A Katz Index score of 0 indicates:
A) Complete independence
B) Complete dependence
C) Mild assistance required
D) Moderate assistance required
B) Complete dependence
