Week 1 Session 1 - PPT Documentation

Question 1

What does SOAP stand for?

Answer 1

Subjective
Objective
Assessment
Plan

Question 2

Match the following meanings of the following scales for the IRF PI?

_____ 06. Independent
_____ 05. Setup or clean-up assistance
_____ 04. Supervision or touching assistance
_____ 03. Partial/moderate assistance
_____ 02. Substantial/maximal assistance
_____ 01. Dependent

A. Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.

B. Patient completes the activity by themself with no assistance from a helper.

C. Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.

D. Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.

E. Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently

F. Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.

Answer 2

06 = B; Independent
Patient completes the activity by themself with no assistance from a helper.

05 = D; Setup or clean-up assistance
Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.

04 = E; Supervision or touching assistance
Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently

03 = F; Partial/moderate assistance
Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.

02 = C; Substantial/maximal assistance
Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.

01 = A; Dependent
Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.

Question 3

What content goes in the S in a SOAP note?

Answer 3

• Report anything significant that the patient and/or family says about his/her/their treatment.
• If patient unable to speak, report non-verbal communication.
• If patient unable to speak or has cognitive/perceptual deficits, you can use the primary caregiver.
• You can quote the patient, paraphrase but be concise.
• Use this time to listen and ask pertinent questions.

Question 4

What content goes in the O in a SOAP note?

Answer 4

• Start with length of OT session and setting
• Observations: measurable (grading and cueing): what did you do?
• Picture of the intervention session
• Adverse event or different behavior and what you did.

Question 5

What content goes into the A in a SOAP note?

Answer 5

• Interpret objective.
• Problems (contributing factors) that are still limiting ADL
• Progress, decline, same
• Rehab potential and why needing more OT.

Question 6

What content goes in the P in a SOAP note?

Answer 6

• Future treatment
• Frequency and duration
• What will you be working on?
• Referral with justification
• Relate from O & A
  Patient to continue with

Question 7

What does RUMBA stand for in goal writing?

Answer 7

Relevant
Understandable
Measurable
Behavioral
Achievable

Question 8

What are the COAST goals?

Answer 8

Client
Occupation
Assist level
Specific condition
Timeline to achieve the goal