Regulatory Issues: Documentation (Week 14) Flashcards
1
Q
Purposes for Client Care Documentation
A
- Client care management
- Referral for other services
- Reimbursement
- Utilization review and management
- Legal document
- Quality management
- Accreditation
- Education and research
- Business development and management
- Client access
2
Q
Documentation in OT
A
- Documentation follows the OT process
-Initial evaluation
-Intervention planning
-Intervention
-Intervention review
-Outcomes - Documentation uses Professional language (OTRF) (Domain and Process)
3
Q
Health Records
A
-Any part of documentation is part of the health record
-Depending on the setting, health records are mainly electronic
-Organized by source-oriented information, integrated information, problem-oriented
4
Q
Types and Formats of Documentation
A
-Types (Handwritten, electronic, mixture)
-Formats (SOAP, DART, PIE, SOAPIE, SBAR, Narrative, Mixture, etc.
5
Q
Documentation Notes
A
- Client name
- Type of documentation
- Date of service
- Problem/goal
- What the client did
- Skilled service provided
- Referrals
- Signature
6
Q
Documentation Rules
A
- Witten in pen if on paper
- Have a date
- Professional terminology
- Acceptable abbreviations
- Legibility
6.
7
Q
SOAP Notes
A
- Subjective
- Objective
- Assessment
- Plan
8
Q
Subjective
A
9
Q
Objective
A
10
Q
Assessment
A
11
Q
Plan
A
12
Q
Structures and systems that create and impact federal and state legislation and regulations
A
13
Q
AOTA
A
14
Q
MBOT
A
15
Q
Payment for Services
A
- Medicare
- Medicaid
- IDEA: Part B/C
- Workman’s Compensation
- Medical Insurance
- Tricare
- Grants
- State Grants
- Quadruple Aim
