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