OCTH 531: Class 20; Documentation, Safety, & TUOS

Who?

When documenting Goals, what component represents the patient or participant?

What?

When documenting Goals, what component represents the areas of occupation, performance skill, & client factors?

How?

When documenting Goals, what component represents the condition, level of assistance of the client, & measurement standard?

When?

When documenting Goals, what component represents when they intend to achieve their goal?

a. The caregiver will facilitate the patient's ability to walk.

A valid goal includes all of the following except:

a. The caregiver will facilitate the patient's ability to walk.

b. The client will return to work within the week.

c. The patient will be able to perform ADLs independently.

d. The client will no longer abuse alcohol.

They are skills required for performance.

Why are client factors important in determining client goals?

Performance area.

If you use the performance component you need to also have a ______ or the “so what?”

Performance component is fine motor coordination.

"The patient will increase right hand fine motor coordination to enable patient to button shirt." What is the Performance component?

Performance area is to button shirt.

"The patient will increase right hand fine motor coordination to enable patient to button shirt." What is the Performance area?

Coping strategies.

"The patient will identify and demonstrate 2 coping strategies when becoming angry enabling them to participate in classroom activities." What is the Performance component?

Classroom activities.

"The patient will identify and demonstrate 2 coping strategies when becoming angry enabling them to participate in classroom activities." What is the Performance area?

Grooming.

"The patient will increase attention span from 2 minutes to 5 minutes enabling them to perform grooming with minimal assistance." What is the Performance area?

Attention span.

"The patient will increase attention span from 2 minutes to 5 minutes enabling them to perform grooming with minimal assistance." What is the Performance component?

c. How.

What goal documentation component is being used:

"Patient will dress upper extremity with minimal assistance and with use of button hook."

a. Who.

b. What.

c. How.

d. When.

Minimal assistance.

"Patient will dress upper extremity with minimal assistance and with use of button hook." What is the measurement standard?

Button hook.

"Patient will dress upper extremity with minimal assistance and with use of button hook." What is the condition?

a. Condition.

Verbal cues or adaptive equipment are considered:

a. Condition.

b. Measurement standard.

b. Measurement standard.

The level of assistance is considered:

a. Condition.

b. Measurement standard.

a. Short term.

Goals written on a weekly or monthly basis are considered to be:

a. Short term.

b. Long term.

Long term goals.

This type of goal is established after a thorough assessment of the patient's strengths and weaknesses, and considers the discharge plan.

Patient has made significantly more or less progress due to a certain factor.

What might cause a long term goal to change?

False.

Short term goals do not need to be related to long term goals.

True or False?

An area of occupation.

For a goal or statement to be functional it must include:

Measurable.

Having the goal include when it will be accomplished makes it:

Grid format.

This format of progress notes is becoming popular and requires less time than SOAP notes.

Subjective.

"The patient complains of difficulty putting on her pants" would be included in what section of SOAP notes?

Subjective.

"The patient states, 'I hate everyone and I want to kill myself'" would be included in what section of SOAP notes?

Objective.

"Initial evaluation indicates that the patient requires max assistance in donning pants. Patient has difficulty with right/left discrimination and displays poor sitting balance. A daily regimen of dressing training has been initiated." would be included in what section of SOAP notes?

Objective.

"The patient attended OT treatment 3 times this week and refused 2 days. Patient made several negative and threatening remarks towards other clients. Client was able to identify triggers and one new coping strategy." would be included in what section of SOAP notes?

Assessment.

"Client seems to have difficulty with dressing skills because of poor balance and perceptual difficulties." would be included in what section of SOAP notes?

Plan.

"Recommend patient attend group 5x/week with focus on anger management, coping and social skills," would be included in what section of SOAP notes?

Assessment.

The therapist's professional opinion would be included in what section of SOAP notes?

1. Gloves,

2. Gown, &

3. Mask.

If necessary, what PPE are associated with universal precautions?

Facility keys.

These items are to always be on your body; never lost or left behind.

1. Phones, &

2. Sharps.

What sorts of items are usually restricted in a Mental Health facility?

It is glass and can be broken and turned into a weapon.

You can expect to not see any mirrors in a Mental Health facility because:

Get permission from Nursing.

What must the OT do before using tools or supplies in a Mental Health setting?

Medication makes them sensitive to Sun.

Why might sunlight be harmful to Mental Health clients?

Elopement risk is high.

Why are doors in Mental Health clinics usually locked?

Nursing or Case manager.

If a client discusses suicide in any way, who does the OT report it to?

1. Ensure the safety of the patient, staff and others.

2. Help patient manage their emotions and distress and maintain or regain control.

What is the goal of CPI training when dealing with an agitated patient?

It may cause them injury and escalate the agitation.

Why do we typically avoid use of restraints when dealing with an agitated patient?

TUOS.

"Planned use of his or her personality, insights, perceptions, and judgments as part of the therapeutic process" is known as:

1. The OT never expects anything in return,

2. The OT is responsible for developing/ maintaining the relationship.

The difference between a Therapeutic Relationship and a Friendship is that in the therapeutic relationship, the OT:

Instructor.

This is one of the 7 Roles of the OT or OTA in a Therapeutic Relationship: teaches a new skill to the patient after analyzing what the patient needs to learn.

Coach.

This is one of the 7 Roles of the OT or OTA in a Therapeutic Relationship: coaxes the patient to participate, supports his efforts and urges him to do better.

Supervisor.

This is one of the 7 Roles of the OT or OTA in a Therapeutic Relationship: oversees patient’s efforts, checks the quality of his work, monitor progress and supplies him with new tasks/challenges.

Role model.

This is one of the 7 Roles of the OT or OTA in a Therapeutic Relationship: Correctly demonstrates the new skill or behavior for learning by imitation.

Problem solver.

This is one of the 7 Roles of the OT or OTA in a Therapeutic Relationship: helps the patient identify problems and set goals for treatment.

Environmental manager.

This is one of the 7 Roles of the OT or OTA in a Therapeutic Relationship: changes the environment to facilitate participation, maximize ability or challenge the patient.

Group member.

This is one of the 7 Roles of the OT or OTA in a Therapeutic Relationship: takes on various roles within the group and is a highly skilled role.

Specificity.

The art of stating things simply, directly and concretely depending on the person's level of function.

Open-ended questions.

To facilitate a more lengthy response, what type of questions should you ask?

Close-ended questions.

To minimize discussion with those who are hyper verbal, what questions should you ask?