OCTA 201 Exam 2 Flashcards
provides a written history to evaluation, intervention, and outcomes of treatment
Documentation
What is the largest funding source for OT services?
Medicare
What is the 1st step in developing an OT treatment plan?
Developing a problem list and behavioral indicators
What is the 2nd step in developing an OT treatment plan?
Prioritizing the list of problems with patients assets (valuables)
What is the 3rd step in developing an OT treatment plan?
Developing goals and objectives
What is the 4th step in developing an OT treatment plan?
Designing activities
What is the last step in developing an OT treatment plan?
Outcomes/discharge planning
What method is used to write goals and objectives?
ABCD method
What does the ABCD method stand for?
A- audience
B- behavior
C- condition
D- degree
Example of ABCD method:
A- Jim
B- verbally lists 3 coping strategies
C- use 1 strategy for the last 10 days
D- within 30 days
What type of note does the OT use to document patient progress or lack of progress?
SOAP note
What does the acronym SOAP stands for?
S- subjective
O- objective
A- assessment
P- plan
What does the “S” (Subjective) in a SOAP note include?
expresses the clients perspective regarding his/her condition or treatment. (ex. limitations, concerns, problems, feelings, attitudes, goals, plans, etc.)
What does the “O” (Objective) in a SOAP note include?
all measurable, quantifiable, and observable data obtained during your clients OT session is recorded. (what the client did, for how long, purpose, and what OTA observed)
What does the “A” (Assessment) in a SOAP note include?
consists of the OT practitioner’s skilled appraisal of the clients progress, functional limitations, pertinent issues, and expected gains from rehabilitation. (3 P’s. problem, progress, potential)
What does the “P” (Plan) in a SOAP note include?
determine and set forth the specific interventions that will be used to achieve the occupational therapy goals. (LTG/STG , frequency and duration of treatment, clients benefits, clients priorities)
what is needed to perform the activity and how that influences or relates to the clients stated goals
Activity Demands
done to the client
Preparatory Methods
done by the client
Preparatory Tasks
What notes are made by the OTA?
Contact notes
Progress Report
What notes are made by the OT?
Reevaluation Report
Transition Plan
Discharge/Discontinuation Report
a legal document that provides an electronic or written history of a clients past and present health, substantiates care, and creates proof of advance directives, vital statistics, course of treatment, and related correspondence
Medical record
What does EMR/EHR stand for?
Electronic medical record
Electronic health record
a EHR used and controlled by the individual rather than the provider or facility, allowing individuals to track and maintain their own health info
Personal health record (PHR)