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