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Documentation of Occupational Therapy Services Flashcards | StudBud
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Documentation of Occupational Therapy Services
Legal aspect of documentation
SOAP notes
Documentation of Occupational Therapy Services
20 terms
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Flashcards
20 cards
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Practice quiz
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Questions
20
Answers
1
SOAP notes
Subjective, Observations, Action, Plan
Provides logical format for organizing information
Subjective, Objective, Assessment, Plan
Used for communicating daily or weekly information
2
Legal aspect of documentation
Use specific facts instead of general terms
Document at the time of tx to ensure accuracy and completeness
Use general terms instead of specific facts
Include supportive documentation
3
What is the purpose of documentation?
Not to be used as a legal record
Provides a sequential & legal record of pt's status & course of tx
Facilitate communication among disciplines involved in pt's care
Provide information about the pt's care
4
What is the purpose of documentation?
Shared as a part of public record
Provide outcome data for use in tx, reimbursement, education, research
Reflect practitioner's reasoning
Justify need for OT
5
If it was not written, it did not happen
True
False
6
Legal aspect of documentation
Document time & length of tx codes/descriptions
Date all entries for accurate sequencing of tx
You're not allowed to document when a client misses tx
Document missed tx
7
There are guidelines that are helpful to ensure the therapist's legal & ethical obligations
True
False
8
Facilities must get from pt a written authorization before giving out health information not related to tx or payment
True
False
9
OT record is comprised of:
Ongoing progress notes
Discharge summary
Re-evaluation reports
Client's complete medical record
10
OTs & OTAs do not have to be familiar with laws protecting pt's information
True
False
11
The completeness and accuracy of documentation is not important
False
True
12
CPT = Current Procedural Terminology
False
True
13
Quality of documentation
Contain as much information as possible
Be objective and accurate
Must be organized
Contain only pertinent information
14
Documentation is private and therefore cannot be used in court
True
False
15
OTs & OTAs mustn't be familiar with classification codes
True
False
16
The legal written record is the only acceptable proof of the tx intervention
True
False
17
Quality of documentation
Be concise
Be subjective
Need not be accurate
Consider the audience of readers
18
Legal aspect of documentation
Do not criticize another healthcare provider
Do not change the legal record after the fact w/o clarifying time/nature
Do not include supportive documentation
You may criticize another healthcare provider if its justified
19
OT record is comprised of:
Daily notes
Initial evaluation
Physician's referral
OTs opinion
20
Codes are used for reimbursement & to classify various types of services rendered
False
True
