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