OCTA 201 Exam 2 Flashcards
provides a written history to evaluation, intervention, and outcomes of treatment
Documentation
What is the largest funding source for OT services?
Medicare
What is the 1st step in developing an OT treatment plan?
Developing a problem list and behavioral indicators
What is the 2nd step in developing an OT treatment plan?
Prioritizing the list of problems with patients assets (valuables)
What is the 3rd step in developing an OT treatment plan?
Developing goals and objectives
What is the 4th step in developing an OT treatment plan?
Designing activities
What is the last step in developing an OT treatment plan?
Outcomes/discharge planning
What method is used to write goals and objectives?
ABCD method
What does the ABCD method stand for?
A- audience
B- behavior
C- condition
D- degree
Example of ABCD method:
A- Jim
B- verbally lists 3 coping strategies
C- use 1 strategy for the last 10 days
D- within 30 days
What type of note does the OT use to document patient progress or lack of progress?
SOAP note
What does the acronym SOAP stands for?
S- subjective
O- objective
A- assessment
P- plan
What does the “S” (Subjective) in a SOAP note include?
expresses the clients perspective regarding his/her condition or treatment. (ex. limitations, concerns, problems, feelings, attitudes, goals, plans, etc.)
What does the “O” (Objective) in a SOAP note include?
all measurable, quantifiable, and observable data obtained during your clients OT session is recorded. (what the client did, for how long, purpose, and what OTA observed)
What does the “A” (Assessment) in a SOAP note include?
consists of the OT practitioner’s skilled appraisal of the clients progress, functional limitations, pertinent issues, and expected gains from rehabilitation. (3 P’s. problem, progress, potential)
What does the “P” (Plan) in a SOAP note include?
determine and set forth the specific interventions that will be used to achieve the occupational therapy goals. (LTG/STG , frequency and duration of treatment, clients benefits, clients priorities)
what is needed to perform the activity and how that influences or relates to the clients stated goals
Activity Demands
done to the client
Preparatory Methods
done by the client
Preparatory Tasks
What notes are made by the OTA?
Contact notes
Progress Report
What notes are made by the OT?
Reevaluation Report
Transition Plan
Discharge/Discontinuation Report
a legal document that provides an electronic or written history of a clients past and present health, substantiates care, and creates proof of advance directives, vital statistics, course of treatment, and related correspondence
Medical record
What does EMR/EHR stand for?
Electronic medical record
Electronic health record
a EHR used and controlled by the individual rather than the provider or facility, allowing individuals to track and maintain their own health info
Personal health record (PHR)
a website through which individuals can access their personal health info at anytime (lab tests results, medications, discharge summaries)
Patient portal
An act passed in 1996 that manages and protects the privacy and security of an individuals health information.
Health Insurance Portability and Accountability Act (HIPAA)
A rule that specified regulations for the use and disclosure of protected health information (PHI)
The Privacy Rule
individuals identifiable health information
Protected Health Information (PHI)
A document given to each patient , delineates the provider’s privacy practices regarding PHI
Notice of Privacy Practices (NPP)
states that only the minimum amount of PHI must be requested or disclosed to accomplish the intended purpose
Minimum necessary
An act passed to establish reforms for health care insurance. Increasing health care assess, lowering costs, providing new protections for consumers, and improving health care quality and efficiency
Patient Protection and Affordable Care Act (ACA)
An act that requires collaboration among the FDA and several other govermental agencies to propose strategies and recommendations for a health IT regulatory framework.
Food and Drug Administration Safety and Innovation Act (FDASIA)
An act that requires long term care hospitals, inpatient rehabilitation facilities, home health agencies, and skilled nursing facilities to submit standardized client assessment data and also report on quality measures and resources use
Improving Medicare Post- Acute Care Transformation Act of 2014 (IMPACT)
An act that addresses the individual needs of infants and children with disabilities and their families
Individuals with Disabilities Education Act (IDEA)
services to children less than 3 years of age who are experiencing a developmental delay in one or more areas
Early intervention
notes typically written in a less restricted paragraph format, although info may still be organized into categories
Narrative note
Users and used of health records:
Client Care Management The Client Reimbursement Clinical Quality Measures The Legal System Research & Evidence-Based Practice Accreditation Education Public Health Business Development
Government funded program that provides health care benefits for active and retired military personnel and their families
TRICARE
A mandatory insurance paid by businesses to cover employees who are injured on the job
Workers Compensation
A federal insurance program for people ages 65 who have permanent disabilities
Medicare
A joint federal and state program that funds health care for eligible low-income people in the US
Medicaid
Services designed to address recovery or improvement in function and, when possible, restoration to a previous level of health and well being
Rehabilitative Therapy
Programs created to help clients maintain present function or slow down/prevent further functional deterioration
Maintenance Program
- An organized way of thinking about human occupation
- Defines and explains a relationship between concepts and ideas concerning occupation
- Theories “predict” events or behaviors regarding occupation
Theory