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Documentation B: Documenting Stages of Intervention Flashcards | StudBud
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Documentation B: Documenting Stages of Intervention
Documentation B: Documenting Stages of Intervention
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Looking at referrals, screens, discontinuation summaries and other forms of documentation.
Flashcards
18 cards
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Practice quiz
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Questions
18
Answers
1
OTA's cannot perform screening of potential patients.
False
True
2
Under Medicare laws, the patent must be _______ in order to be covered for skilled OT services.
seriously injured.
85 years or older.
treated in conjunction with PT.
under the care of a physician.
3
A request to complete an OT evaluation is a:
Telephone order.
Referral.
Screen.
Transition Plan.
4
What document summarizes the client's occupational status and lists follow-up recommendations?
Contact Note
Reevaluation
Transition Plan
Progress Note
5
A physcian writes an order for OT tx evaluate for severe lower abdominal pain and swelling.
This is within our scope of practice. We'll take it!
We are not doctors. Not happening!
6
What is an OTA responsible for in regards to an appeal letter?
Ensuring that all interventions are goal oriented
Communicating patient's status effectively
Concise and clear documentation
All of these
7
During a screening, you need to look for:
scores on standardized test.
blood pressure.
specific measurements.
occupational concerns.
8
The plan for discharge should include:
DME recommendations.
An HEP.
All of these.
Follow up recommendations.
9
Who can be a referral point for occupational therapy?
Nurses
Parents
Physical Therapists
All of these
10
Contact notes can vary depending on the practice setting.
False
True
11
The primary documentation of an event during which someone has been injured is called:
Transition Plan.
Incident Report.
Colbert Report.
Screen.
12
Why is good documentation important?
It ensures that our patients/their families understand tx.
We get reimbursed for great work if it is well documented.
Insurance companies are evil and don't want to pay for OT.
ALL OF THESE
13
What form of documentation is required when a patient chooses to stop participating in tx.
Discontinuation Summary.
Progress Note.
Contact Note.
Transition Plan.
14
Screenings are:
non-billable
billable
15
A progress note should include:
current client performance.
the plan or recommendations.
summary of services provided.
all of these.
16
Clients may be reevaluated monthly, quarterly, or:
daily
as needed
yearly
weekly
17
Screenings should be very detailed and paint a complete picture of the potential patient.
False
True
18
In Tennessee, a physician must complete a referral before OT can evaluate a patient.
False
True
