Midterm

Question 1

Why we document:

Answer 1

To outline what occurred: services provided
Articulate for the client
To inform others
Legal reasons
3rd party payers- insurance

Question 2

Professional communication

Answer 2

Tone, active voice vs. passive voice, non-discriminatory language

Question 3

Methods:

Answer 3

Memos, letters, email, phones, fax, text

Question 4

Frames of Reference vs Models of Practice

Answer 4

FOR: a bridge between theory & practice
Guides your treatment and your documentation

FOR: behavioral, biomechanical, Canadian MOP, Cog-behavior, developmental, MOHO, NDT, PDF, Sensory

Question 5

Top-Down:

Answer 5

Focus: Clients’ performance in areas of occupation and then other aspects later such as client factors, performance skills and patterns, activity demands, context and environment.
Primary focus is the client’s ability to engage in meaningful occupations.

Question 6

Bottom-Up:

Answer 6

Focus: Improve the performance skills and then the client’s performance in areas of occupations will improve.

Question 7

Referrals:

Answer 7

suggestions from someone that a client would benefit from OT – the referral will go to the OTR

Question 8

Orders:

Answer 8

written physician referral

Question 9

Screening

Answer 9

brief assessment to determine if a complete eval is needed. COTA’s can contribute to this.

Question 10

Assessment:

Answer 10

tool used to observe, to get the functional abilities and limitations of a client

Question 11

Role Delineation:

Answer 11

OTR: evaluation process, summarizing, analyzing and interpreting
OTA: contribute to evals, screenings and assessments

Question 12

Restorative Goals

Answer 12

focus on identifying an occupation that the patient can no longer engage in, used when injury or illness has impacted the clients’ ability to engage in that occupation when they were able to at their base line.

Question 13

Habilitative Goals

Answer 13

Focus is on promoting person’s ability to engage in a new occupation or development of a new skill. Oftentimes used with children who have developmental delays

Question 14

Maintenance Goals

Answer 14

focus on maintaining current abilities, to reduce risk of decreased function- not paid for by insurances (no progress)

Question 15

Preventative Goals

Answer 15

Focus is on preventing someone who is at risk of developing performance problems. (i.e. repetitive motion injury/self harm)- promotion of good body mechanics

Question 16

Health Promotion Goals

Answer 16

Focus on enrichment or enhancement of occupational performance. Can apply to individuals, groups, communities, or organizations.

Question 17

Modification Goals

Answer 17

Compensation or adaptation goals, focus on changing the contexts or activity demands rather than changing the skills of the client

Question 18

Goals:

Answer 18

The just right challenge
Client centered and developed in collaboration with the client
OTR makes the goals but the OTA can contribute

Question 19

Writing a goal: COAST

Answer 19

C: Client
O: occupation
A: assist level
S: specific condition
T: time line

Question 20

SOAP note

Answer 20

S: Subjective: comments and or reports about problems, complaints, etc.
Information should be relative to treatment, verbal or nonverbal, can be a quote
O: Objective: Record Observation
Data, Measures, Facts, PT performance, client’s reactions to intervention
A: Assessment:
Pt deficits, pt strengths, pt level of motivation
Every A must have evidence of the S and O
No new information, just summary
P: Plan:
Does this pt need further OT intervention?
Include frequency, duration, and intensity

Question 21

Evidence- based practice

Answer 21

Helps awareness, consultation, judgment and creativity
5 steps to find evidence
1: define question
2: select appropriate information
3: best database or printed sources
4: modify search
5: Modify question for best information

Question 22

School documentation:

Answer 22

Difference between IEP and IFSP: (googled)
The major difference between an IFSP and an IEP is that an IFSP focuses on the child and family and the services that a family needs to help them enhance the development of their child. The IEP focuses on the educational needs of the child.
IFSP is based on an in-depth assessment of the child’s needs and the needs and concerns of the family. It contains 1) information on the child’s present level of development in all areas; 2) outcomes for the child and family; and 3) services the child and family will receive to help them achieve the outcomes
IEP is an education document for children ages 3 to 21. It focuses on special education and related services in schools.

Practical information to be aware of as a practitioner:
Similarities and differences between clinical documentation and school documentation: