Evaluation & Assessment Flashcards

1
Q

What is the Health Insurance Portability Act and Act (HIPAA)?

A

Federal standards for security, use, and disclosure of a client’s protected health information

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2
Q

What are the HIPAA privacy rules?

A
  • Prevents unauthorized disclosure of a client’s PHI
  • Right to view and obtain a copy of the health record
  • Right to request revision or omission of info in the health record that is incorrect
  • right to know how health info is used & shared
  • Right to decide if PHI can be used for purposes of marketing & research
  • Right to authorize the release of health information to selected individuals
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3
Q

What are the 2 parts to a functional problem statement?

A
  • area of occupation that is a concern
  • contributing factors to that area of occupation
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4
Q

Where would you find a problem list?

A

Under the patient’s initial assessment

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5
Q

What are the MUST’s for occupation-based goals & objectives?

A
  • written in occupation-based, measurable, observable,
    action-oriented
  • realistic & achievable for the client with a reasonable amount of time within current practice setting
  • problem list compiled in collaboration with the client.
  • focus on functional improvements in occupational performance
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6
Q

What is COAST?

A

Client- person, organization & population
Occupation- only format to include this
Assistance- any required for participation, verbal, physical, etc
Specific conditions- needs in correlation to goal
Timeline-

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7
Q

What are the components of a SOAP note?

A

S: subjective
- clients concerns & experience
- Relevant information
- How it happened
- The occupation-– when does it hurt?
- Where they feel pain

O: objective
- show need for service
- quantifiable/ measurable data
- chronological
- observable

A: assessment
- 3 P’s: Problems, Progress & Potential
- Your clinical reasoning
- Justification for continuation of services

P: plan
- frequency
- duration
- Purpose of services
other ot should be able to read & be able to proceed

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