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OT 101 > Module 2: Documentation in OT Practice > Flashcards

Module 2: Documentation in OT Practice Flashcards

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1
Q

What are the two types of records?

A
  1. Clinical Records
  2. Administrative/Departmental Records
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2
Q

These contain information that relate to patient care such as OT notes, referral notes, assessment notes, etc.

A

Clinical Records

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3
Q

These are records created for administrative purposes such as Statistical Records, Personal Management Records, Equipment and Supply Records, and Financial Records.

A

Administrative or Departmental Records

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4
Q

Who are the audiences for OT documentation?

A
  1. Medical professionals
  2. Educators
  3. Accreditation agencies
  4. Payers
  5. Client & Caregiver
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5
Q

The documents’ goals and purpose are clearly stated.

A

“Function & Purpose” in documentation

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6
Q

The documents’ are capable of being understood and transmitted.

A

Communicability in documentation

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7
Q

Documents achieve consistency for comparison purposes.

A

Standardization in documentation

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8
Q

The application of physical appearance technicalities in documents.

A

“Form Development & Design” in documentation

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9
Q

Confidentiality is practiced and clinic owns all records.

A

“Ownership and Retention” in documentation

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10
Q

The reporting and interpretation of clients’ responses on assessments and interventions in a medical record.

A

Clinical documentation

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11
Q

Essential features of clinical documentation (6)

A
  1. Date of completion of report
  2. Full signature & credentials
  3. Type of document
  4. Client name & case number on each page
  5. Acceptable abbreviations
  6. Acceptable terminology
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12
Q

What are the documents under the Initiation stage of OT?

A
  1. Screening document
  2. Evaluation document
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13
Q

Taken prior to an evaluation

A short note usually written summarizing the conversation and the results

A

Screening

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14
Q

Reports written by OT to document the start of intervention

Containts factual data collected during the process and its interpretation

A

Evaluation

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15
Q

Contents of evaluation reports (8)

A
  1. Identifying & background information
  2. Referral information
  3. Evaluation procedures / tests used
  4. Occupational profile
  5. Findings & results
  6. Interpretation of results
  7. Plan of intervention
  8. OT’s signatures & credentials
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16
Q

It contains a prioritized problem list, the goals related to the problem, and the desired potential functions and improvements

A

Intervention Plan Document

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17
Q

Types of goals

A
  1. Long-term goals
  2. Short-term goals
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18
Q

Change in occupational limitations and change in participation restriction occur

Occurs prior to the termination of intervention wherein desired functional outcomes are achieved

A

Long-term goals

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19
Q

Component subskills which are to be achieved over short time frames

Successively lead to the attainment of the LTG

A

Short-term goals

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20
Q

In writing a goal statement, the _____ structure is mostly used in the Philippines:

A

ABCD (Audience - Behavior - Conditions - Duratio)

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21
Q

LTG’s and STG’s should be written in the _____ structure

A

SMART (Specific - Measurable - Attainable - Realistic - Timebound)

22
Q

In SMART, it refers to tangible outcomes

What does the client want to do?

A

Specific

23
Q

In SMART, it gives concrete data on the degree of client’s performance

It is essential for reimbursement and tracking progress

A

Measurable

24
Q

In SMART, client must want to reach their goals because they are realistic

A

Realistic

25
Q

In SMART, it is the duration for how long goals are meant to be done

A

Time-bound

26
Q

What is the CARE format

A

Clarity - Accuracy - Relevance - Exceptions

27
Q

Contains the procedures to be used, clients’ response to activities, goal modifications when indicated for, attendance or absence from treatment plan, and more

A

Intervention Implementation Documentation

28
Q

What are the documents under Documentation for Continuing OT Services?

A
  1. Progress notes
  2. Clinical/OT notes
29
Q

These periodically document care coordination and interventions.

Updates progress towards functional and treatment plan goals.

Describes clients’ reactions

A

Progress notes

30
Q

Documents individual OT sessions

Done briefly, usually every day or after every session

A

OT/Clinical notes

31
Q

In writing the Progress and OT notes, the _____ format is used

A

SOAP (Subjective - Objective - Assessment - Plan)

32
Q

In SOAP format, it pertains to the client’s own experiences and the information reported by their families and close peers

A

Subjective

33
Q

In SOAP format, it pertains to the clinician’s informed observations, measurements, and data obtained through assessments

A

Objective

34
Q

In SOAP format, it is the therapist’s interpretation and clinical reasoning based on the gathered data, analysis of client’s status and goals.

A

Assessment

35
Q

In SOAP format, it is the therapist’s specific steps of intervention to resolve identified problems and meet goals.

A

Plan

36
Q

What is the BIRP format?

A

Behavior - Intervention - Response - Plan

37
Q

What is the RUMBA format?

A

Relevant - Understandable - Measurable - Behavioral - Achievable

38
Q

What is the POMR format and its 2 subformats?

A

Problem Oriented Medical Record

  1. SOAP (Subjective - Objective - Assessment - Plan)
  2. RUMBA (Relevant - Understandable - Measurable - Behavioral - Achievable)
39
Q

What are the documents under Discontinuing OT services?

A
  1. Endorsement notes
  2. Discharge notes
40
Q

Documents client’s basic information, problems, and improvement for treatment continuation.

Made for a client’s new OT if they transfer.

A

Endorsement notes

41
Q

What do Endorsement Notes contain? (6)

A
  1. Client’s basic information
  2. Referral services requested
  3. Problems list
  4. Activities given during sessions
  5. Improvements and progress made
  6. Recommendations
42
Q

Used as a summary of the course of the whole therapy and any recommendations

Written at the end of the therapy

A

Discharge Notes

43
Q

What do Discharge notes contain?

A
  1. Therapy process
  2. Goal attainment
  3. Functional outcomes
  4. Follow-up recommendations
  5. Home instruction program
  6. OT signature & credentials
  7. Date
44
Q

The therapeutic problem-solving method used by practitioners to help clients improve occupational performance

Theory-based and data-driven

A

Occupational therapy

45
Q

6 Major Components of Occupational Therapy

A
  1. Theory
  2. Evaluation
  3. Problem Definition
  4. Intervention Planning
  5. Intervention Implementation
  6. Re-evaluation
46
Q

A component of Occupational Therapy wherein practitioners systematically collect & organize data about occupational performace

A

Evaluation

47
Q

A component of Occupational Therapy wherein data is synethesized, forming a profile of the client’s abilities and disabilities to be delienated.

A

Problem Definition

48
Q

A component of Occupational Therapy wherein specific occupational therapy strategies & modalities to eliminate problems are proposed.

A

Intervention Planning

49
Q

A component of Occupational Therapy wherein intervention plan is operationalized and actions are initiated to achieve outcomes.

A

Intervention Implementation

50
Q

These are established to mark the endpoints of therapy and serve as markers of intervention plan’s effectiveness.

A

Outcomes

51
Q

A component of Occupational Therapy that involves the recollection of data gathered during Evaluation stage to see if activities and interventions relay changes.

A

Re-Evaluation

OT 101 (9 decks)

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