stud
bud
Sign up
Log in
Home
Library
Explore
SAT
More
Documentation Guidelines Final Review Flashcards | StudBud
Explore
/
Documentation Guidelines Final Review
Documentation Guidelines Final Review
140 terms
·
StudBud Administration
Imported from external platform
Flashcards
140 cards
F
Practice quiz
P
Host live
L
Questions
140
Answers
1
In the COAST method, what does the “A” represent?
Action plan
Assessment procedure
Area of occupation
Assist level
2
Which of the following is not true about subjective information in a SOAP note?
It includes the patient’s feelings and concerns
It can include information from family or other providers
It must be objectively measurable
It can include relevant quotes from the patient
3
What format is commonly used for daily contact notes?
Question-and-answer
Full assessment form
Insurance billing form
Narrative or chronological
4
Which of the following best describes the “O” (Objective) section of a SOAP note?
Measurable, observable data from the session
Therapist’s opinion on progress
Data that cannot be verified or measured
The patient’s personal goals
5
What source of information is MOST helpful in developing a client-centered problem list?
Client’s insurance policy
The therapist’s textbook
The client interview and goals
Family’s medical history
6
What is the purpose of a functional problem statement in occupational therapy documentation?
To summarize the therapist’s opinion of the client
To list the client’s medical diagnoses
To justify billing codes
To describe how a client’s conditions limits their participation
7
What does ICD in ICD codes stand for?
Internal Coding Design
International Classification of Diagnosis
Individual Client Diagnosis
International Classification of Diseases
8
What should not be included in the “A” section?
New medical information not found in “S” or “O”
Summary of inconsistencies between report and observation
Interpretation of observed functional limitations
Statement justifying continued treatment
9
Which statement would be appropriate to include in the “S” section?
Pt expressed frustration with inability to dress self
Pt would benefit from continued OT to dress self
Increase therapy to 30 min 5x/week for 3 weeks
Pt able to complete 10 reps of sit<>stand with supervision
10
In school settings, what is a key requirement of OT goals?
They must use the COAST format only
They must focus on discharge planning
They must be focused on ADLs only
They must be team-driven and educationally relevant
11
What is a common characteristic of post-acute settings?
24/7 physician monitoring
Focus on emergency care
Only available to private insurance holders
Services may be provided at home or in the community
12
Which of the following is an example of justifying continued OT services?
Pt reports ongoing back pain
Pt was sleepy and unmotivated
Pt completed 3/5 therapy tasks
Recommend continued OT for increased (I) in dressing using AE
13
Which of the following examples shows proper specificity in subjective documentation?
“Client said they have pain.”
“Client had pain in upper body.”
“Client said their left shoulder hurts when reaching for high shelves.”
“Client stated pain is in arm.”
14
Clinical or critical care pathways are most commonly used for which type of condition?
Orthopedic procedures
Chronic fatigue syndrome
Brain injuries
Acute mental illness
15
Which of the following behaviors does not reflect the qualities of a well-written “O” note?
Concise and specific terminology
Using standard abbreviations
Emphasizing what the OTA did during treatment
Using measurable observations
16
Who are the two primary audiences for objective documentation in OT?
Pt’s family and caregivers
OT/OTA and pt’s family
OT/OTA and school administrators
OT/OTA and untrained readers (e.g., insurance or doctors)
17
Which of the following best describes a Material Safety Data Sheet (MSDS)?
A document detailing safe handling of chemicals and hazardous materials
A legal document outlining patient rights
A therapy protocol sheet
A billing form for occupational therapy
18
Which of the following best represents subjective information?
Client completed 10 reps of shoulder flexion
Therapist observed limited shoulder range of motion
Client performed grooming tasks with moderate assistance
Client stated, “My arm hurts every time I reach overhead”
19
Which of the following is most appropriate to include in the objective section under description of function?
Ct used a tripod grasp to pick up 5 pegs within 30 sec using (R) hand
Ct had a good attitude
Ct did the activity fast
Ct picked up the pegs very quickly
20
What type of information belongs in the “S” (Subjective) section of a SOAP note?
Therapist’s professional interpretation
Patient’s feelings or statements about their symptoms
Plan for future sessions
Number of reps completed during an exercise
21
Why is the “P” section important in continuity of care?
It ensures billing codes are recorded
It allows another therapist to continue treatment consistently
It serves as a copy of the physician’s orders
It summarizes the entire treatment plan in detail
22
What is the primary purpose of the occupational profile?
To assign diagnosis codes
To develop a financial plan for services
To gather information on the client’s roles, routines, values, and goals
To determine discharge location
23
Which of the following is NOT typically a justification for skilled maintenance therapy?
Establishing a safety program
Training unskilled personnel
Patient performing the entire program independently
Re-evaluating the program periodically
24
Which document designates someone to make healthcare decisions on your behalf if you become incapacitated?
Advanced directive
Healthcare proxy
Power of attorney
Living will
25
In the COAST method for writing goals, what does the “O” stand for?
Objective
Outcome measurement
Occupation
Observation
26
What should a discharge (D/C) note include?
Summary of treatment, goal status, and recommendations
Insurance and billing details
Summary of therapy goals only
Diagnosis and treatment plan
27
What statement about rehab potential is most appropriate for Medicare documentation?
Ct does not show any signs of improvement
Ct is not motivated to improve
Ct rehab potential is guarded
Ct has good rehab potential for stated goals
28
In which category would difficulty performing home maintenance tasks due to decreased strength best fit?
IADL function
Context and environment
Activity demands
Leisure activities
29
Which of the following statements belongs in the “A” section of a SOAP note?
Pt used RUE to hold hairbrush
Pt requires v/c for sequencing due to decreased problem-solving skills
Pt completed grooming with min A
Pt reported feeling tired during ADL tasks
30
Which of the following would not be appropriate for the “S” section?
“Ct reported fatigue after dressing”
“Ct c/o difficulty sleeping due to back pain”
“Spouse stated ct seemed confused this morning”
“Ct AMB 100 ft with RW”
31
Which statement best shows proper documentation of patient response and skilled service?
Ct brushed hair for 10 min
Ct brushed hair on request
Ct practiced brushing hair
Ct brushed hair with built-up handle comb with min A and v/c for sequencing
32
What is the correct level of assistance for a client who performs less than 50% of the task?
Minimal assistance
Maximal assistance
Modified independence
Moderate assistance
33
Which OT service focuses on helping a client gain or improve skills for daily living for the first time?
Maintenance care
Habilitative care
Rehabilitative care
Preventative care
34
What does “therapeutic use of self” involve in occupational therapy practice?
Working alone to set treatment goals
Planned use of one’s personality, perceptions, and judgements in therapy
Using PAMs like heat and ice
Letting the client choose their own treatment plan
35
What are examples of performance skills evaluated during occupational analysis?
Nutrition and hydration levels
Reflexes and balance
Motor, process, and social interaction skills
Emotional regulation and memory recall
36
Why is it important to include assistance levels in problem statements?
To make the note easier to read
To record the caregiver’s workload
To ensure physician approval
Because they are measurable and clarify the client’s abilities
37
Which intervention approach aims to “maintain performance skills” and assumes skills would decline without OT?
Maintenance
Establishment of skills
Modification
Health promotion
38
What two factors must be included in the “P” section regarding scheduling?
Session length and caregiver name
Time of day and therapist’s availability
Frequency and attendence
Frequency and duration
39
What documentation responsibility does an OTA have in the discharge process?
Create new goals for home therapy
Contribute written input from treatment and progress notes
Sign off on the discharge summary without supervision
Initiate the discharge independently
40
Which of the following settings requires daily physician monitoring and focuses on client stabilization?
Skilled nursing facility
Home health
Acute care
Outpatient rehabilitation
41
Which is a recommended strategy for making OT notes sound more professional?
Use full sentences and avoid all abbreviations
Use standard and approved abbreviations only
Focus on tools and equipment used
Write from the OTA’s perspective
42
What is the primary function of the “P” section in a SOAP note?
To interpret test results
To outline future therapy interventions
To report subjective patient statements
To list a client’s medical history
43
What is the purpose of a transition plan in documentation?
To provide information to the next service provider when changing settings
To document missed appointments
To summarize a client’s medical history
To record daily treatment notes
44
Which of the following is the best example of a goal that is valued by the client?
Ct will practice buttoning for 15 minutes
Ct will tolerate PROM exercises daily
Ct will complete 10 reps of shoulder flexion
Ct will prepare a simple breakfast (I) within 1 week
45
What type of listening is used to gather answers to specific questions?
Courteous
Attentive
Analytic
Directed
46
What type of program is designed to maintain function and may be covered if designed and instructed by OT/OTA?
Rehabilitative care program
Preventative care program
Acute care program
Maintenance program
47
When is a re-evaluation or reassessment note typically completed?
Based on setting, progress, or funding source requirements
Monthly, regardless of client needs
After every session
Only upon discharge
48
What is the primary purpose of an incident report?
To alert legal authorities
To document routine treatment
To record unforeseen occurrences such as falls or medication errors
To be placed in the patient’s medical record
49
How should pain be addressed in documentation?
Recorded only in the Assessment section
Treated as a subjective report and supported with rating scales
Listed as an objective measure
Ignored unless observed by the OTA
50
Which tool is commonly used to measure a client’s self-perception of performance and satisfaction in daily activities?
FIM
MoCA
COPM
DASH
51
Which of the following is an appropriate example of a problem identified in the “A” section?
Pt tolerated therapy well
Pt smiled during activity
Lack of elevator access prevents ct from returning to work
Pt’s increased UE strength
52
Which of the following shows a proper interpretation of patient potential?
Pt is able to use AE with min A during feeding, showing increased (I)
Pt stated she would try harder
Pt used walker to walk 10 feet
Pt plans to return to school
53
Which of the following best describes “person-first language”?
Referring to someone as “wheelchair-bound”
Putting the person before their disability (e.g., “person with a stroke”)
Describing a person by their condition
Emphasizing the diagnosis over the individual
54
What type of documentation would include a summary of progress and final recommendations?
Contact note
Initial evaluation
Progress note
Discharge note
55
What must be true about all information in the “A” section?
It is newly introduced data
It is based only on standardized tests
It is reported by the patient
It is derived from and supported by the “S” and “O”
56
What does the term “activity demands” refer to when analyzing a functional limitation?
The physical and cognitive skills required to perform the activity
The time it takes to complete an activity
The diagnosis related to the activity
The resources available in the client’s environment
57
Which ethical principle requires OT practitioners to contribute to the good health and welfare of the client?
Veracity
Autonomy
Non-maleficence
Beneficience
58
What is the primary purpose of quality improvement (QI) in healthcare documentation?
Improve billing practices
Reduce staff workload
Limit the use of electronic records
Lead to measurable improvements in healthcare services
59
Which intervention type involves collaborating to make recommendations without providing direct treatment?
Advocacy
Education
Therapeutic use of self
Consultation
60
Which of the following is an example of a contributing factor in a problem statement?
Ct has dx of Parkinson’s disease
Ct demo decreased fmc
Ct would like to improve handwriting
Ct is unable to complete dressing (I)
61
Which documentation includes client attendance, participation, and response to AE during a session?
Treatment Note/Daily Contact Note
Transition Plan
Evaluation Report
Discharge Summary
62
According to Medicare Part B, how may an OTA modify a short-term goal?
With physician approval only
Under the direction of an OTR and documented with clinician name and date
During client evaluations only
Independently whenever needed
63
Which of the following would NOT be an appropriate contributing factor in a problem statement?
Structural limitation
Sensory impairment
Neuromuscular dysfunction
Lack of motivation
64
Which part of the COAST goal addresses when the client will achieve the goal?
C
S
T
O
65
Which document must include the OTA’s signature and professional designation?
SOAP note template
Treatment note
Weekly schedule
Client intake form
66
What does the “A” section help justify?
Discharge from all therapies
Continued need for skilled OT services
Reduction in therapy time
Referral to a different provider
67
Medicaid is funded and managed by:
Both state and federal governments, managed by the state
State only
Federal government only
Private insurance companies
68
Why is the SOAP format commonly used in healthcare documentation?
It emphasizes only objective data
It focuses on billing needs
It avoids including patient concerns
It provides a logical method to organize clinical information
69
What distinguishes a daily note from a progress note in OT documentation?
Daily notes include only information from that specific visit
Daily notes summarize the entire treatment episode
Progress notes exclude subjective input
Progress notes are only used in inpatient settings
70
What is a key purpose of the “A” (Assessment) section?
Interpreting the data from the S and O sections
Documenting new subjective information
Recording the patient’s vital signs
Restating the interventions provided
71
When an OTA wishes to modify the treatment plan, what must occur?
Record the change in the “S” section
Notify the insurance provider
Consult with the supervising OT
Contact the client directly
72
Which program provides healthcare to active-duty service members, their families, and survivors?
Veterans Health Administration
Tricare
Workers’ Compensation
Medicare Part C
73
What is the key characteristic of occupation-based interventions?
The focus is only on preparatory exercises
The intervention is passive
It involves group therapy
The activity is directly related to the client’s goals and daily life
74
The “P” section can also be used to:
Record vital signs
Introduce new goals not discussed previously
Track visits completed or remaining
Document past medical history
75
Which of the following is a private source of healthcare reimbursement?
Medicaid
Worker’s Compensation
HMO (Health Maintenance Organization)
Medicare
76
What communication skill is especially important when gathering subjective data?
Effective listening
Giving commands
Prioritizing treatments
Delegating tasks
77
If a patient is nonverbal, which statement would be appropriate to include in the “S”?
“Client tolerated session well.”
“Client required max assistance for grooming.”
“Client unable to express needs; mother stated client was fatigued today.”
“Client sat upright for 10 minutes with support.”
78
What is a key characteristic of professional documentation?
Timely, legible, and objective entries
Avoiding abbreviations under all circumstances
Use of casual language to improve readability
Use of red ink for emphasis
79
Which of the following is a dimension of quality care?
Billing frequency
Confidentiality
Timeliness
Sustainability
80
Which of the following is a federal health insurance program that includes Part A, B, C, and D options?
Medicaid
Workers’ compensation
Medicare
Tricare
81
What is a key role of OT practitioners in the continuum of care?
Managing insurance claims
Diagnosing medical conditions
Discharge planning based on client independence and support
Prescribing medication
82
What should you do if a patient refuses treatment?
Cancel all future treatments
Document the refusal with date, time, and circumstances
Ignore and attempt treatment anyway
Only notify the patient’s family
83
Which of the following statements is TRUE about advanced directives?
They are the same as insurance documents
They allow individuals to state their healthcare wishes if incapacitated
They are not legally recognized in most states
They specify financial arrangements after death
84
What type of health information disclosure is allowed under HIPAA for law enforcement without patient authorization?
Reporting a death suspected to result from criminal conduct
Social media activity of patients
Patient billing records
Details of psychological assessments
85
Which type of documentation is used to communicate ongoing daily treatment and observations?
Contact note
Discharge summary
Transition plan
Initial evaluation
86
Why is using the phrase “Pt. would benefit from skilled OT” important in the Assessment section?
It helps justify billing
It reflects what the patient wants
It outlines future intervention frequency
It documents subjective feelings
87
Which covers inpatient hospital care, SNF care, hospice, and some home health services?
Medicare Part C
Medicare Part B
Medicare Part A
Medicare Part D
88
Which of the following is considered a preparatory method in OT intervention?
Role-playing social situations
Completing grocery shopping with a patient
Using electrical stimulation to reduce pain
Teaching a client to manage money
89
What does a discharge (D/C) plan typically include?
The therapist’s resume
A list of all previous interventions
Service provider’s credentials
Estimated end date of OT services and future recommendations
90
Which of the following would not be appropriate to include in the “O” section?
Pt reports feeling anxious about session
Pt performed grooming task with mod A using adaptive comb
Pt able to complete 10 reps of shoulder flex using 3# wt
Pt UE AROM measured at 80* shoulder flex
91
Adapting an activity typically involves:
Removing all physical demands of a task
Modifying objects or the method to complete the task
Teaching the client to complete the task faster
Increasing task complexity
92
The assessment section of the SOAP note is often referred to as:
The client’s voice
The administrative portion
The heart of the note
The factual summary
93
What is the primary difference between long-term goals (LTGs) and short-term goals (STGs)?
LTGs are used in mental health settings only
STGs are the steps to achieve LTGs
STGs must be more general than LTGs
LTGs are client-driven, while STGs are therapist-driven
94
Which of the following would be the most appropriate entry in the “O” section?
“Ct reported feeling tired after walking”
“Ct needs to get better at using walker”
“Ct is upset about pain in their shoulder”
“Ct AMB 30 ft with RW and CGA x1 for safety”
95
What is the main goal of the Patient-Centered Medical Home (PCMH) model?
Focus only on physical health
Increase emergency visits
Deliver coordinated care for the whole person
Eliminate the role of the family in care
96
Which role is responsible for directing the evaluation process and developing the intervention plan?
Case manager
OTA
Rehabilitation aide
OTR
97
What does the “O” in a SOAP note stand for?
Occupation
Objective
Observation
Overview
98
In Missouri, who is legally required to report suspected child abuse?
All mandated reporters directly to social services within one day
Only supervisors or administrators
Only after confirmation by a team
Only law enforcement
99
What is a face sheet used for?
Monitoring daily attendance
Summarizing evaluation findings
Collecting demographic and insurance information
Recording therapy goals
100
What is a common tool used to help clients describe their pain in a subjective format?
Pain rating scale (0-10)
FIM
MMT
ROM goniometer
101
Which of the following best describes grading in occupational therapy?
Using assistive technology to complete the task
Increasing or decreasing task demands to match the client’s ability
Replacing a task entirely with a new occupation
Changing the environment to simplify the activity
102
Which of the following statements would be most appropriate for the “O” section?
Pt completed 15 min of grooming tasks with min A.
Pt appears motivated to return to work.
Pt reports pain in (L) hand.
Pt will continue therapy 3x/week.
103
What is the main purpose of the “A” section in a SOAP note?
To document interventions provided
To summarize the patient’s medical history
To list the patient’s subjective complaints
To interpret the data from the S and O sections
104
Which of the following documents summarizes progress and effectiveness of interventions over a set period?
Progress report
Treatment note
Intake form
D/C summary
105
What must be included on every page of OT documentation?
Client’s goals and outcomes
Client’s name and case/medical record number
Client’s name and date of birth
Diagnosis and physician’s name
106
What is a critical requirement when measuring progress over time using objective data?
Use the same tools and procedures each time
Ask for subjective feedback only
Avoid measuring progress more than once
Change up the test method each session
107
In a problem statement, what does the phrase “unable to” indicate?
Ct refuses to participate
Task is partially completed by ct
Ct can complete task with min support
There is absence of fx, indicating complete (D)
108
What is a requirement for OT services to be reimbursed by Medicare?
The client must be under 65 years old
Services must be provided by a rehabilitation aide
The client must live in a rural area
Services must be skilled, reasonable, and medically necessary
109
According to HIPAA, which of the following is considered protected health information (PHI)?
Preferred leisure activities
Room number and meal preference
Medical record number and diagnosis
Gender and marital status
110
Which statement appropriately reflects clinical planning in the “P” section?
Will consult OTR regarding adaptive strategies for dressing
Ct daughter asked about DME options
Ct required max A with toileting today
Ct is showing signs of depression
111
Which of the following is most likely to be found in the “P” section?
“Ct reports fatigue during sessions.”
“Pt completed ADL training with mod A.”
“Pt’s progress demo improved safety awareness.”
“Ct will continue OT 3x/week for 2 more weeks to improve (I) in ADLs.”
112
Which component is NOT typically analyzed during occupational performance analysis?
Necessary actions and tools
Context and environment
Sequence and timing of tasks
Client’s insurance eligibility
113
Which of the following is the BEST example of a functional problem statement?
Ct cannot raise arm above shoulder height
Ct has rotator cuff tear
Ct reports pain and fatigue
Ct requires mod A for UB dressing due to decreased shoulder AROM
114
Which of the following is an example of a well-written COAST goal?
Ct will increase strength and ROM by end of treatment.
Ct will dress independently.
Ct will use AE.
Ct will perform UB dressing with min A using a reacher within 2 weeks.
115
Who is responsible for completing the initial evaluation report?
OTA
OT student
OTR
Admissions staff
116
Which of the following best describes appropriate terminology for the “O” section?
Ct used (R) hand kind of slow
Ct was good at brushing teeth
Ct completed grooming task with smooth, controlled movement using RUE
Ct’s movement looked fine
117
Which of the following best demonstrates an action-oriented goal?
Client will think about using coping strategies
Client will perform lower body dressing while seated
Client will discuss exercise with family
Client will understand the importance of range of motion
118
Which of the following is NOT typically included in an occupational profile?
Cognitive testing scores
Interests and values
Occupational history
Daily roles and routines
119
Which of the following situations allows a hospital to disclose patient information to law enforcement?
When criminal conduct occurs on hospital property
When a patient tells staff they are unhappy
When a patient refuses treatment
When a visitor requests the information
120
According to AOTA guidelines, which of the following must be included in an intervention plan?
Measurable, occupation-based goals and objectives
A list of the client’s medications
The client’s insurance provider
Only the therapist’s goals
121
Which legislation promotes the use of electronic health records (EHRs) to improve quality and safety?
HITECH
HIPAA
IDEA
FERPA
122
Which of the following must be included in a well-written functional problem statement?
The diagnosis and medication list
Medical test results
The occupation impacted and the contributing factor
The caregiver’s opinion
123
What is a key purpose of writing objective notes in OT documentation?
To explain the patient’s emotions
To record a therapist’s opinion
To prove treatment efficacy with measurable data
To summarize medical history
124
Which of the following best describes the content of the Assessment section?
The OTA’s clinical reasoning and interpretation
Objective measures of performance
Daily session notes only
The patient’s emotional report
125
What legislation expanded access to affordable healthcare and emphasized prevention and quality outcomes?
Patient Protection and Affordable Care Act (ACA)
HIPAA
The Health and Safety Code
Medicare Act
126
Which healthcare model coordinates care across settings and receives a single lump-sum payment per episode?
Fee-for-visit
PPO
Pay-for-service
Bundled payment
127
Which of the following would justify the need for continued OT services in the “P” section?
Ct has no complaints
Ct will continue OT to address deficits in dynamic balance during transfers
Ct attended all previous sessions
Family requested therapy be extended
128
What is a key focus of modern healthcare reformation?
Reducing technology use in therapy
Increasing hospital admissions
Emphasis on wellness and prevention
Volume-based delivery
129
The “P” section is typically written in which tense?
Future tense
Past tense
Present tense
Conditional tense
130
Which is an example of advocacy in occupational therapy practice?
Using a splint to reduce swelling
Educating a caregiver on safe transfers
Demonstrating a dressing technique
Writing a letter of medical necessity for a wheelchair
131
In a SOAP note, what does the “S” represent?
Statement
Summary
Symptoms
Subjective
132
What is the purpose of the “Assessment” section in a SOAP note?
To list detailed objective measurements
To describe the plan for future care
To summarize the practitioner’s clinical reasoning
To record the client’s subjective input
133
What does the “P” section communicate about discharge planning?
It demonstrates clinical reasoning related to future discharge needs
It includes patient satisfaction scores
Patient has no more goals to meet
It reflects current vital signs to determine readiness
134
Which method helps gather client-centered goals through structured conversation and builds self-efficacy?
Visual memory assessments
Range of motion screening
Motivational interviewing
Physical performance testing
135
Which of the following is the most measurable and observable goal component?
Client will demonstrate ability to button a shirt using a button hook
Client will feel better when using adaptive equipment
Client will improve balance over time
Client will understand dressing techniques
136
Which billing code system is used to report outpatient OT services and is owned by the AMA?
SNOMED
CPT
DSM-5
ICD-10
137
Which of the following is a benefit of electronic health records (EHRs)?
Allows point-of-service documentation and care coordination
Reduces need for documentation
Increases paperwork redundancy
Eliminates need for client input
138
Which of the following is a correct feature of the “P” (Plan) section?
It includes the OTA’s opinion of the client’s progress
It outlines what will happen in future OT sessions
It should only summarize what happened in the last session
It includes measurable goals and evaluation findings
139
What does a score of “6” on the levels of assistance scale indicate?
Minimal contact assistance
Modified independence
Supervision or setup
Complete independence
140
Under what condition is maintenance therapy covered by Medicare?
When skilled therapy is required for training caregivers
If the therapy takes place in a hospital
When it can be provided by family members
Only when the patient demonstrates functional improvement
