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