Evaluation & Assessment Flashcards
What is the Health Insurance Portability Act and Act (HIPAA)?
Federal standards for security, use, and disclosure of a client’s protected health information
What are the HIPAA privacy rules?
- 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
What are the 2 parts to a functional problem statement?
- area of occupation that is a concern
- contributing factors to that area of occupation
Where would you find a problem list?
Under the patient’s initial assessment
What are the MUST’s for occupation-based goals & objectives?
- 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
What is COAST?
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-
What are the components of a SOAP note?
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
