Deck 7: Documentation of Occupational Therapy Services

Question 1

The Medicare 700 form ________________.

A) Does not require that all sections be completed
B) Is used for outpatient evaluations of Medicare clients
C) Has unlimited space for documentation
D) Can never be replaced with modified versions

Answer 1

B
It is important to fill in all spaces on the Medicare 700 form.Failure to complete a section of the form could result in a technical denial.The Medicare 700 form is the Medicare-specified form for outpatient evaluations.Space on the 700 form is limited,and the therapist must be able to concisely present data that will clearly demonstrate the need for OT.Many rehabilitation companies and hospitals have modified the 700 form with headings and checklists to assist the therapist in providing the type of information that will support the need for therapy services.

Question 2

Which of the choices below is not true of skilled services?

A) They require analysis and modification of functional tasks.
B) They include provision of instructions to the client, family, or caregivers.
C) Evaluation is a skilled service.
D) No revising or readjusting of the program is necessary.

Answer 2

D
Documentation of skilled services must reflect the therapeutic rationale for the service.Progress toward established goals must be described,and goals should be updated and modified on the basis of the client's progress.

Question 3

The establishment of goals should be ______________.

A) Determined by the therapist only
B) Determined by the doctor
C) Determined by the client and therapist collaboratively
D) Determined by the client's caregiver or guardian

Answer 3

C
Goals should be established collaboratively by the client and the therapist.If the client is unable to participate,then the goals are established collaboratively by the therapist and the client's caregiver or guardian.

Question 4

Which term below is not an example of skilled terminology?

A) Analyze
B) Maintain
C) Facilitate
D) Design
E) Adapt

Question 5

Which statement below is not true?

A) HIPAA stands for the Health Insurance Portability and Accountability Act.
B) HIPAA clearly outlines the expectations of health care professionals in issues of confidentiality.
C) HIPAA provides federal protection of PHI.
D) There are no federal laws to protect the consumer against breaches of confidentiality.

Question 6

Individually identifiable health information _____________.

A) Refers to only recent medical information about the client
B) Is also known as protected health information (PHI)
C) Can be disposed of with the regular trash
D) Can be shared casually among the client's family members

Question 7

Data recorded in the objective section of the note could include which of the following?

A) Orders in the referral
B) Specific degrees of measurement of range of motion (ROM)
C) List of activities performed by the client
D) Interpretation of the client's measurements

Question 8

Which statement below is incorrect?

A) Goals are written to reflect what the therapist will do.
B) Client-centered goals are written with input from the client.
C) Goals reflect what the client will do.
D) Goals should be measurable and objective and should include a time frame.

Question 9

Which term is not a section of a SOAP note?

A) Subjective
B) Objective
C) Analysis
D) Plan

Question 10

Narrative reasoning is used __________________.

A) To help the therapist understand the client's disabilities, impairments, and performance contexts
B) To evaluate the meaning that occupational performance limitations might have on the client
C) When addressing practical realities associated with delivery of OT services
D) To determine the most appropriate therapy intervention to address the client's occupational performance needs

Question 11

How often is documentation required?

A) Daily
B) Weekly
C) Monthly
D) Whenever occupational therapy (OT) services are provided

Question 12

An occupational profile does not include information about the client's ___________.

A) Patterns of daily living
B) Occupational history and experiences
C) Values and interests
D) Needs
E) Past medical history

Question 13

Which of the following is not included as subjective part of a SOAP note?

A) Information reported by the doctor
B) Information reported by the client
C) Information reported by the caregiver
D) Information reported by the family

Question 14

Safety measures to prevent unauthorized persons from accessing client records include which of the following?

A) Requiring personal identification and user verification codes for access to records
B) Sharing login pass codes among staff
C) Working on notes from home
D) Leaving computer up and accessible in front of clients

Question 15

Which of the following statements is not correct?

A) Computerized documentation is becoming more common.
B) Computerized documentation can be used to record all aspects of the OT process from the evaluation report to the discharge report.
C) All documentation must be computerized.
D) Computerized documentation guarantees legibility and helps ensure that no areas are left uncompleted.