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