The 3 P's: problems, progress and potential are put in this section of the SOAP format of documentation.
What is Assessment?
100
This is a summary of client's ability between initial evaluation & discontinuation of service.
What is a discharge report?
100
Some settings prefer to use the APSO version of this common documentation format.
What is SOAP
100
Occupational therapy documentation should always record practitioners activity in these areas.
What are screening, evaluation, interventions and outcomes?
200
Information from the interview goes in this section of SOAP.
What is Subjective?
200
This formal plan is documented when client moves from one setting to another within a service delivery system?
What is a transition plan?
200
A Resident Assessment Instrument is to be documented as per Medicare regulations, in this setting.
What is a SNF
200
These are 4 types of intervention documentations.
What are the intervention plan, service contacts (logs), progress report (note) and the transition plan?
300
An example of this section of SOAP might include: continue 1 hour daily sessions for 1week. Within 1 week, client will demonstrate ability to put arms in holes of shirt 50% of time.
What is Plan?
Note: *What 2 SOAP sections could it also be put into?
300
A summary of the intervention process and progress toward goals is in this type of documentation.
What is a progress note?
300
Positioning the screen out of the view of others while documenting is complying with this regulation.
What is HIPPA
300
Documentation should always be done in accordance with these entities.
What are the payer, facility, state and federal guidelines?
400
The statement: Client seen for 1 hour in clinic kitchen for skilled instruction in compensatory techniques for cooking- goes under this section of SOAP.
What is objective?
400
Instructing client in a 1-handed cooking technique is best documented as this type of intervention strategy.
What is compensatory?
400
An OT that violates the Occupational Therapy Code of Ethics would be censured by this body.
What is NBCOT?
400
Precautions & contraindications are indicated in this type of documentation.
What is indicated in all types of documentations from a screening to a discharge report.
500
Therapy goals are written in this section of SOAP.
What is Plan (Borcherding, 2008).
500
Attendance & participation may be recorded in this type of service contact document.
What is a service log?
500
This is the regulatory agency that has influenced how we document rehabilitation service.
What is CARF? Commission on accreditation of Rehabilitation Facilities)
500
These are three principles that guide contemporary occupational therapy Practice and should be reflected in documentation.
What are client-centered practice, occupation-based practice and evidence-based practice?