Week 14 and 15

Question 1

The Purpose of Client Care Documentation

Answer 1

-Client care management, referral for other services, reimbursement, utilization review, legal document, quality management, accreditation, education, business, development, client access

Question 2

Documentation in OT

Answer 2

-Initial evaluation (Occupational Profile, Assessment Results), Intervention planning, Intervention, Intervention review, Outcomes
-Documentation uses professional language (OTPF) (Domain & Process)

Question 3

Health Records

Answer 3

-Any documentation is part of the health record
-Mainly electronic
-EHRs are organized by. source-oriented information, integrated information, problem-oriented

Question 4

Formats of Documentation

Answer 4

-Handwritten, electronic, mixture
-Formats: SOAP, DART, PIE, SOAPIE, SBAR, SOAPIER, FOCUS

Question 5

Documentation Notes

Answer 5

-Client name/ Case #, type of document, date of service, problem/goal, what the client did, skilled service provided, referrals, signature

Question 6

Documentation Rules

Answer 6

-Must have a date, no spaces, grammar, professional terminology, legibility, proofread, etc.

Question 7

“S” in SOAP Notes

Answer 7

Subjective
-What the client says

Question 8

“O” in SOAP Notes

Answer 8

Objective
-What you saw the client for
-Observe the client doing or the barriers that prevented the, from doing
-Measurement from assessments results
-De-emphasize/reclassify the treatment activity

Question 9

“A” in SOAP Notes

Answer 9

Assessment
-Professional opinion about the O section
-impact of client factors on other occupational areas or function
-Why is skilled service needed

Question 10

“P” in SOAP Notes

Answer 10

Plan
-Therapist’s plan for treatment
-What will happen next
-Communication and collaboration the need to refer client for other services

Question 11

Structures and systems that create and impact federal and state legislation and regualtions

Question 12

AOTPAC

Answer 12

Further the legislative aims of the Association by influencing or attempting to influence the selection, nomination, election, or appointment of any individual to any Federal public office, and of any occupational therapist, occupational therapy assistant, or occupational therapy
student member of AOTA seeking election to public office at any level.

Question 13

Minnesota Board of Occupational Therapy

Answer 13

To protect the public through effective licensure and enforcement of the statutes and rules governing occupational therapy practice to ensure a reasonable standard of competent and ethical practice.
-Verifies that practitioners are qualified to practice OT in MN

Question 14

Payment for Services

Answer 14

-Public/Government, Idea (Part B and C), Workman’s compensation,

Question 15

Payment Rules: Medical Settings

Answer 15

Billing is usually in 15-minute increments called
units table 3-6 page 27
– Billing codes
– ICD-10 – condition codes
– CPT codes: treatment codes
– Payment is based on outcomes Patient Driven
Payment Model (PDPM)
– MDS- Minimum Data Set
– Form used to assess where a client is at and
what services/supports are required for care
– Section F for activities staff
– Section G for Rehab
– Billed based on skilled services/Outcomes
– Tracks patient outcome

Question 16

Influence of Payer Systems on Documentation

Question 17

HIPPA

Answer 17

Health Information and Portability Act

Question 18

FERPA

Answer 18

Family Educational Rights and Privacy Act

Question 19

Ethical Considerations

Answer 19

– Documentation is a legal record
– Denials/Appeals
– Illegible, Incomplete, Abbreviations unknown, Complete list on page 26
– AOTA is resource for up-to-date information
– CMS.gov
- Regulations, Supervision, Billing
– Billing fraud
– High productivity issues (now less, but other ways will surface, Facilities pushing to increase caseload or keep patients longer than they should or doing group therapy
– Students who document must have co-signer of
supervisor
-COTAs may have to have documentation co-signed
(depending on type of workplace and regulations in
place)
– Rehab Aides are not allowed to document

Question 20

NBCOT Exam

Question 21

COTA Domain

Answer 21

1. COLLABORATING AND GATHERING INFORMATION
   * Assist the OTR to acquire information regarding factors that influence
   occupational performance on an ongoing basis throughout the occupational
   therapy process. 28%
2. SELECTING AND IMPLEMENTING INTERVENTIONS
   * Implement interventions under the supervision of the OTR in accordance with
   the intervention plan and level of service competence to support client
   participation in areas of occupation throughout the occupational therapy
   process. 55%
3. UPHOLDING PROFESSIONAL STANDARDS AND RESPONSIBILITIES
   * Uphold professional standards and responsibilities by achieving service
   competence and applying evidence-based interventions to promote quality in
   practice. 17%

Question 22

Minnesota Licensure

Question 23

Credentials to work with reimbursors

Answer 23

1. Medicare 65+ y/o federal program
   -Want registered/credentialed therapists
2. Medicaid Medical Assistance
3. Private Insurance
   -Often specify the registered therapist

Question 24

Standards of Practice

Answer 24

Official document of the profession used to define the minimum standards for the practice and delivery of OT
1. Defines the education, examination and licensure requirements
2. Definition of terms
3. Professional Standing and Responsibility
4. Service Delivery
5. OT Process
6. Helps practitioners and organizations determine what should and what can be
done
7. Ethical guide

Question 25

Code of Ethics

Answer 25

1. Identify and describe the principles supported by OT profession
2. Educate general public about principles OT practitioners are accountable for
3. Socialize OT personnel new to the practice
4. Assist OT personnel in recognition and resolution of ethical dilemmas

Question 26

Benefience

Answer 26

A concern for the safety and well-being of the individual.
-Protecting and defending the rights of others, preventing harm form occurring to others, removing conditions that will cause harm to others, offering services that benefit person with disabilities, and acting to protect and remove person from dangerous situations.

Question 27

Nonmaleficence

Answer 27

Take measures to refrain from actions that causes harm.
-Includes an obligation not to impose risks of harm even if the potential risk is without malicious or harmful intent
-Benefits of care outweigh and justify the risks undertaken to achieve the goals of care

Question 28

Autonomy

Answer 28

Respect the right of the person to self-determination, privacy, confidentiality, and consent.
-Duty to treat the client or service recipient according to their desires, within the bounds of accepted standards of care, and to protect their confidential information

Question 29

Justice

Answer 29

Promote equity, inclusion and objectivity in the provision of services
-Fair equitable, and appropriate treatment of persons, fair, equitable, and appropriate treatment of persons
-Respect laws and standards related to practice

Question 30

Veracity

Answer 30

Providing consumers with comprehensive, accurate, and objective information.
-Truthfulness
-Veracity is based on the virtues of truthfulness, candor, honesty , and respect owed to others

Question 31

Fiedelity

Answer 31

Treat clients, persons, groups, population, colleagues and other professionals with respect, fairness, discretion, and integrity.
-Maintenance of respectful collegial and organizational relationship

Question 32

Disciplinary Action

Answer 32

1. Reprimand - Letter, private
2. Censure - Formal expression of disapproval, public
3. Probation - Failure to meet terms will subject a member to any actions or sanctions
4. Suspension - Removal of membership for a specified time
5. Revocation - Permanent denial of membership

Question 33

Solving Ethical Problems

Answer 33

1. Ethical Distress
   * Gut feeling, something is not right
   * Need to work through an ethical decision process
2. Ethical dilemma
   * Situation where one or more ethical principles are in conflict
3. Locus of authority
   * Who can make the decision?