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