Documentation Final Study Guide

Settings in which an OTA may be required to complete documentation

Hospital

Skilled nursing facility

Acute care

Inpatient rehab

Outpatient rehab

Schools

Home health

Pediatric clinic

Types of documentation OTAs may be asked to generate/contribute to

Daily note

Progress note

Contact note

Assessment

Evaluation

Discharge note

D/c note

Transition plan

Reevaluation note

What is HIPPA?

HIPPA is a law that protects the privacy of patients. Under this legislative protection, a patient's medical history and conditions are kept confidential and medical practitioners are not allowed to share them with others who are not participants in the patient's treatment.

Black ink only is acceptable in medical documentation

True

It is acceptable to use white out in the medical record

False

It is not acceptable to erase in the medical record

True

Scribbling or writing over a letter, number or word is never acceptable in medical documentation

True

It is acceptable to use department-specific abbreviations in the medical record

True

Good documentation helps the practitioner recall the patient and the treatment provided

True

A complete SOAP note should paint a picture of what occurred in the treatment session

True

Correct spelling is not important in the medical record

False

It is acceptable to refer to the OTA as “the therapist” in your documentation

False

It is acceptable to document for someone else’s session if they run out of time and you were present for the treatment

False

You do not need to worry about signing and dating your SOAP note as anyone reading it will know that you wrote it

False

Compare skilled services/professionals to non skilled

1. Skilled services have specific criteria and are performed by qualified professionals.  They require professional education, decision making and highly complex competencies.

2. Nonskilled services are defined as those that are routine or maintenance, that can be carried out by nonprofessionals or caregivers.

3. Practitioner must demonstrate the client’s potential for functional improvement, or intervention is necessary for equipment recommendations, or to address a specific medical need.

Types of skilled intervention

Education

Instruction

Remediation

Training

Fall prevention

Self advocacy

Does the following statement belong in the subjective or objective section of the SOAP note? 

15 min session in OT gym for functional transfer practice

Objective

Does the following statement belong in the subjective or objective section of the SOAP note?

“I did not sleep well last night.”

Subjective

Does the following statement belong in the subjective or objective section of the SOAP note? 

Pt.'s spouse reports that pt. required increased oxygen during bathing last night.

Subjective

Does the following statement belong in the subjective or objective section of the SOAP note? 

Difficulty with midline orientation in unsupported sit noted; mod (A) to achieve and maintain midline with (B)UE support

Objective

Rewrite the following statement without abbreviations.

Pt. required CGA for w/c ↔ toilet utilizing FWW and min v/c.

The patient required contact guard assist for transferring to and from the wheelchair and the toilet utilizing front wheeled walker and minimum vital capacity

Rewrite the following statement without abbreviations.

(B)UE strength G

Bilateral upper extremity strength graded good

Rewrite the following statement so that it is specific to OT practice with professional verbiage and abbreviations, as needed. Provide which section of the SOAP note this statement belongs in.

 

The dyspraxic kid said she tripped on her shoelaces and fell on her butt, causing a large black and blue mark

The child with dyspraxia reported tripping over her shoelaces and falling onto her ischium, causing a large bruise.

Belongs in the subjective section of the SOAP note

Rewrite the following statement so that it is specific to OT practice with professional verbiage and abbreviations, as needed. Provide which section of the SOAP note this statement belongs in.

 

The lady was unable to wash her left armpit because she could not lift her bad left shoulder.

Due to the pt.'s inability to lift her weak (L) shoulder, the client was unable to wash her (L) axilla.

This statement belongs to the objective section of the SOAP note.

Rewrite the following statement so that it is specific to OT practice with professional verbiage and abbreviations, as needed. Provide which section of the SOAP note this statement belongs in.

 

The patient walked 3 feet to the shower with some help so he wouldn't fall

Pt ambulated 3 ft to the shower /c mod (A).

O section of SOAP note.

Match the following professional language for anatomy and bodily function terms:
Arm

Upper extremity

Match the following professional language for anatomy and bodily function terms:

Under the tongue

Sublingual

Match the following professional language for anatomy and bodily function terms:

High muscle tone

Hypertonicity

Match the following professional language for anatomy and bodily function terms:

Low muscle tone

Hypotonicity

Match the following professional language for anatomy and bodily function terms:

Close to part of body

Proximal

Match the following professional language for anatomy and bodily function terms:

Further away from part of body

Distal

Match the following professional language for anatomy and bodily function terms:

Throw up

Emesis

Match the following professional language for anatomy and bodily function terms:

Underarm

Axilla

Match the following professional language for anatomy and bodily function terms:

Leg

Lower extremity

Match the following professional language for anatomy and bodily function terms:

Blood clot

Thrombus

May be a requirement needed to justify further treatment sessions

Re-evaluation plan

Documentation written at the end of a specified period of time

Progress report

Documentation of what occurred during the tx session

Daily visit note/contact note

Written when the pt is transferring to another facility

Transition plan

Includes recommendation of DME, adaptive devices, splints or home programs; also includes referrals or follow up as needed

Discharge note (DC plan)

Documentation completed by the OT; varies between settings

Initial evaluation

What does SOAP stand for?

Subjective

Objective

Assessment

Plan

What does the abbreviation COTA stand for?

Certified Occupational Therapy Assistant

BUE

Bilateral upper extremity

Codes used to bill for individual procedures, prosthetics, orthotics or supplies.

CPT

Funding for those under the age of three who are experiencing a developmental delay.

Early intervention

Federal Insurance program for individuals 65 years or older, or those younger than 65 who have a permanent disability.

Medicare

Joint federal and state programs that funds health care for eligible low income people.

Medicaid

Codes used to classify the spectrum of health-related conditions, injuries, diseases and disorders worldwide.

ICD-10

Identify if the following statements belong in either the “S”, “O” or “A” section of a SOAP note

Child treated in OT clinic to promote development of FM skills for BADL

Objective

Identify if the following statements belong in either the “S”, “O” or “A” section of a SOAP note

Decreased motor planning is a barrier to client’s ability to dress upper body.

Assessment

Identify if the following statements belong in either the “S”, “O” or “A” section of a SOAP note:

Patient required min A for threading R affected side while donning a open-front shirt, undergarments and pants sitting on edge of bed.

Objective

Match the Functional Level of Assist:

Independent

Pt consistently performs ALL aspects of activity safely and effectively, including set-up without physical assistance or verbal cues WITHOUT assistive devices OR extra time.

Match the Functional Level of Assist:

Modified Independent

Pt consistently performs ALL aspects of activity safely and effectively, including set-up without physical assistance or verbal cues WITH assistive devices AND/OR extra time.

Match the Functional Level of Assist:

Set Up Assistance

Patient requires placement of necessary items before being able to perform task.

Match the Functional Level of Assist:

Standby Assist/Supervision

Pt performs MOST aspects of activity safely but requires some near assistance which includes set up of supplies or verbal cueing for  safety and/or technique.

NO hands on physical assist

Match the Functional Level of Assist:

Contact Guard Assist

Pt can usually perform activity without assist but has a greater likelihood for needing IMMEDIATE physical assistance. Requires therapist to be beside the patient with physical contact holding onto a gait belt or touching patient shoulder or back.

Must be ready to provide immediate physical help to steady or assist with task

Match the Functional Level of Assist:

Minimal Assist

Pt can perform at least 75% of activity but requires physical assistance/ weight bearing support to complete activity safely and effectively

Match the Functional Level of Assist:

Moderate Assist

Pt can perform at least 50 % of activity but physical assist is required to complete activity safely and effectively.

Match the Functional Level of Assist:

Maximal Assist

Pt can perform at up to 25% of activity requiring more than 75% physical assistance to complete the task safely and effectively.

Pt effectively actively assists with task

Match the Functional Level of Assist:

Total Assist

Pt cannot perform activity and requires complete physical assist for task completion.  May require more than one person for safety.

Pt may ineffectively attempt to actively assist with task