Random
You saw a pt for 25 minutes how many units do you bill?
What is 2 units
What does I stand for when describing a patient's assistance level?
What is “independent”
What does SMART stand for when writing goals?
What is Specific, Measurable, Achievable, Relevant, and Time-bound
What does SOAP stand for?
Subjective, Objective, Assessment, Plan
Is "Patient did awesome today" professional documentation?
What is "No. It is vague and subjective"
What is a CPT code?
What is a number used to describe a medical service or treatment that a healthcare provider performs
What does c/o mean?
What "is complains of”
Should an OT goal focus on what the therapist does or what the patient will be able to do?
What is "what the pt will be able to do"
What type of note summarizes function and recommendations when OT services end?
What is a discharge note
Should you document a treatment that did not actually occur?
What is "No. Documentation must be accurate and truthful"
Why is HIPAA important?
What is protects patients' private health information
What does w/c mean?
What is “wheel chair”
Why should goals include a time frame?
What is to identify when the expected outcome should be achieved
What should an OTA do if the patient's performance declines compared with previous sessions?
What is document the change and communicate with the OTR and other team members about the pt
Why should documentation be completed timely and ASAP?
What is to support communication, and reduce the risk of forgetting important details
When should a treatment session be documented?
What is as soon as possible
What does NWB stand for?
What is “non-weight bearing”
A patient will button their shirt with minimal assistance in two weeks. What makes this a measurable goal?
What is identify the task, assistance level, and time frame.
Why might a progress note include updated goals?
What is to reflect the patient's current abilities, progress, and continuing need for treatment
What should you do if you are unsure how to document a situation?
Ask the supervising OT or follow facility documentation policies
What should you do if you make a mistake in a medical record?
What is correct your mistake according to facility policy while preserving the original entry and audit trail
What does WFL mean?
What is “Within Functional Limits”
Why should OT goals focus on occupations and daily activities?
What is "to improve participation, function, and independence in meaningful activities"
A patient says, "My shoulder hurts today." Which SOAP section?
What is subjective section
The OTA will continue practicing dressing skills using adaptive equipment during the next session. Which SOAP section?
What is P section