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