Module 2: Documentation in OT Practice

Question 1

What are the two types of records?

Answer 1

1. Clinical Records
2. Administrative/Departmental Records

Question 2

These contain information that relate to patient care such as OT notes, referral notes, assessment notes, etc.

Answer 2

Clinical Records

Question 3

These are records created for administrative purposes such as Statistical Records, Personal Management Records, Equipment and Supply Records, and Financial Records.

Answer 3

Administrative or Departmental Records

Question 4

Who are the audiences for OT documentation?

Answer 4

1. Medical professionals
2. Educators
3. Accreditation agencies
4. Payers
5. Client & Caregiver

Question 5

The documents’ goals and purpose are clearly stated.

Answer 5

“Function & Purpose” in documentation

Question 6

The documents’ are capable of being understood and transmitted.

Answer 6

Communicability in documentation

Question 7

Documents achieve consistency for comparison purposes.

Answer 7

Standardization in documentation

Question 8

The application of physical appearance technicalities in documents.

Answer 8

“Form Development & Design” in documentation

Question 9

Confidentiality is practiced and clinic owns all records.

Answer 9

“Ownership and Retention” in documentation

Question 10

The reporting and interpretation of clients’ responses on assessments and interventions in a medical record.

Answer 10

Clinical documentation

Question 11

Essential features of clinical documentation (6)

Answer 11

1. Date of completion of report
2. Full signature & credentials
3. Type of document
4. Client name & case number on each page
5. Acceptable abbreviations
6. Acceptable terminology

Question 12

What are the documents under the Initiation stage of OT?

Answer 12

1. Screening document
2. Evaluation document

Question 13

Taken prior to an evaluation

A short note usually written summarizing the conversation and the results

Answer 13

Screening

Question 14

Reports written by OT to document the start of intervention

Containts factual data collected during the process and its interpretation

Answer 14

Evaluation

Question 15

Contents of evaluation reports (8)

Answer 15

1. Identifying & background information
2. Referral information
3. Evaluation procedures / tests used
4. Occupational profile
5. Findings & results
6. Interpretation of results
7. Plan of intervention
8. OT’s signatures & credentials

Question 16

It contains a prioritized problem list, the goals related to the problem, and the desired potential functions and improvements

Answer 16

Intervention Plan Document

Question 17

Types of goals

Answer 17

1. Long-term goals
2. Short-term goals

Question 18

Change in occupational limitations and change in participation restriction occur

Occurs prior to the termination of intervention wherein desired functional outcomes are achieved

Answer 18

Long-term goals

Question 19

Component subskills which are to be achieved over short time frames

Successively lead to the attainment of the LTG

Answer 19

Short-term goals

Question 20

In writing a goal statement, the _____ structure is mostly used in the Philippines:

Answer 20

ABCD (Audience - Behavior - Conditions - Duratio)

Question 21

LTG’s and STG’s should be written in the _____ structure

Answer 21

SMART (Specific - Measurable - Attainable - Realistic - Timebound)

Question 22

In SMART, it refers to tangible outcomes

What does the client want to do?

Answer 22

Specific

Question 23

In SMART, it gives concrete data on the degree of client’s performance

It is essential for reimbursement and tracking progress

Answer 23

Measurable

Question 24

In SMART, client must want to reach their goals because they are realistic

Answer 24

Realistic

Question 25

In SMART, it is the duration for how long goals are meant to be done

Answer 25

Time-bound

Question 26

What is the CARE format

Answer 26

Clarity - Accuracy - Relevance - Exceptions

Question 27

Contains the procedures to be used, clients' response to activities, goal modifications when indicated for, attendance or absence from treatment plan, and more

Answer 27

Intervention Implementation Documentation

Question 28

What are the documents under Documentation for Continuing OT Services?

Answer 28

1. Progress notes 2. Clinical/OT notes

Question 29

These periodically document care coordination and interventions. Updates progress towards functional and treatment plan goals. Describes clients' reactions

Answer 29

Progress notes

Question 30

Documents individual OT sessions Done briefly, usually every day or after every session

Answer 30

OT/Clinical notes

Question 31

In writing the Progress and OT notes, the _____ format is used

Answer 31

SOAP (Subjective - Objective - Assessment - Plan)

Question 32

In SOAP format, it pertains to the client's own experiences and the information reported by their families and close peers

Answer 32

Subjective

Question 33

In SOAP format, it pertains to the clinician's informed observations, measurements, and data obtained through assessments

Answer 33

Objective

Question 34

In SOAP format, it is the therapist's interpretation and clinical reasoning based on the gathered data, analysis of client's status and goals.

Answer 34

Assessment

Question 35

In SOAP format, it is the therapist's specific steps of intervention to resolve identified problems and meet goals.

Answer 35

Plan

Question 36

What is the BIRP format?

Answer 36

Behavior - Intervention - Response - Plan

Question 37

What is the RUMBA format?

Answer 37

Relevant - Understandable - Measurable - Behavioral - Achievable

Question 38

What is the POMR format and its 2 subformats?

Answer 38

Problem Oriented Medical Record 1. SOAP (Subjective - Objective - Assessment - Plan) 2. RUMBA (Relevant - Understandable - Measurable - Behavioral - Achievable)

Question 39

What are the documents under Discontinuing OT services?

Answer 39

1. Endorsement notes 2. Discharge notes

Question 40

Documents client's basic information, problems, and improvement for treatment continuation. Made for a client's new OT if they transfer.

Answer 40

Endorsement notes

Question 41

What do Endorsement Notes contain? (6)

Answer 41

1. Client's basic information 2. Referral services requested 3. Problems list 4. Activities given during sessions 5. Improvements and progress made 6. Recommendations

Question 42

Used as a summary of the course of the whole therapy and any recommendations Written at the end of the therapy

Answer 42

Discharge Notes

Question 43

What do Discharge notes contain?

Answer 43

1. Therapy process 2. Goal attainment 3. Functional outcomes 4. Follow-up recommendations 5. Home instruction program 6. OT signature & credentials 7. Date

Question 44

The therapeutic problem-solving method used by practitioners to help clients improve occupational performance Theory-based and data-driven

Answer 44

Occupational therapy

Question 45

6 Major Components of Occupational Therapy

Answer 45

1. Theory 2. Evaluation 3. Problem Definition 4. Intervention Planning 5. Intervention Implementation 6. Re-evaluation

Question 46

A component of Occupational Therapy wherein practitioners systematically collect & organize data about occupational performace

Answer 46

Evaluation

Question 47

A component of Occupational Therapy wherein data is synethesized, forming a profile of the client's abilities and disabilities to be delienated.

Answer 47

Problem Definition

Question 48

A component of Occupational Therapy wherein specific occupational therapy strategies & modalities to eliminate problems are proposed.

Answer 48

Intervention Planning

Question 49

A component of Occupational Therapy wherein intervention plan is operationalized and actions are initiated to achieve outcomes.

Answer 49

Intervention Implementation

Question 50

These are established to mark the endpoints of therapy and serve as markers of intervention plan's effectiveness.

Answer 50

Outcomes

Question 51

A component of Occupational Therapy that involves the recollection of data gathered during Evaluation stage to see if activities and interventions relay changes.

Answer 51

Re-Evaluation