General OT Process
During an evaluation, you may use “a specific tool, instrument or protocol to gather data and describe client factors, performance skills, and performance patterns." This may be standardized or unstandardized.
Assessment
True or False: You may write a SOAP note on another therapist's behalf if you observed the treatment.
You collaborate with all Kindergarten teachers in an elementary school to incorporate a fastener board station into their daily center stations. This approach to intervention is:
A) Create/promote
B) Establish/restore
C) Maintain
D) Modify
E) Prevent
A) Create/Promote
Creating experiences and enriching contexts to enhance occupational performance
What element of COAST is missing in this goal?
By the 6th treatment session, client will
participate in dressing activities for at least 10 minutes with CGA for balance.
S: Specific condition
What section of the SOAP note does this statement belong:
"Pt demonstrates difficulty with dressing due to left side neglect."
Assessment
An OT must receive a _______ from the physician in order to begin the OT process (with an evaluation).
Referral
Before an occupational therapy student can submit documentation, it must be ________ by the OTR/L.
Cosigned
This is an example of:
A) Modifying the task
B) Modifying the objects
C) Modifying the environment
B) Modifying the objects
***GROUP QUESTION***
Write a concise COAST goal based on the following problem statement:
Impairments in attention and sequencing result in client needing max A meal prep.
Client will complete simple meal prep in clinic kitchen with mod A for attention and sequencing by 12/15/2024.
(Or an acceptable version of the above)
True or False: If you didn’t mention it in the “S” or “O,” you shouldn't talk about it in the “A.”
True
This part of the evaluation comes from interviewing the client. It should provide an explanation of the client's occupational history and experiences, patterns of daily living, interests, values, and needs.
Occupational Profile
You are scoring a written assessment and write a number in the wrong column. How should this error be corrected?
Strikethrough the error and initial
(May include "mistaken entry" depending on setting-specific guidelines)
A client who wants to regain independence in meal preparation is working on making a simple meal in the clinic's kitchen.
True or False: This is an example of a bottom up approach.
False
A client needed help with approximately 60% of a toileting task. What level of assistance was provided?
Max A
Client performs 25-49% of the activity
The 4 "P's" of the assessment section include problems, progress, and ________.
Potential
In what step of the OT Process are goals written?
A) Analysis of occupation
B) Intervention implementation
C) Synthesis of evaluation
D) Outcomes
C) Synthesis of evaluation
The IFSP is a type of setting-specific documentation that pertains to what setting?
Early intervention
(Individualized Family Service Plan)
***GROUP QUESTION***
You are working with a young adult with an intellectual disability on the IADL of "Care of Pets," specifically feeding her cat.
Name one way to grade this activity up and one way to grade it down.
Grading up: Increasing task demands/complexity
Ex- Selecting correct measuring cup out of multiple options prior to scooping food, giving multiple verbal directions at once, etc.
Grading down: Decreasing task demands/complexity
Ex- Using pre-measured food, providing a checklist of instructions, etc.
What's wrong with this goal?
Client will shower with min A and moderate verbal cues with use of shower chair in 2 weeks.
Mixing assistance levels (min A and cues)
The two ways information can be organized in the "O" section.
C_________ and C __________
Chronologically and categorically
***GROUP QUESTION***
Arrange the steps of the occupational therapy process in the correct order:
Intervention Review
Occupational Profile (interview)
Outcomes
Intervention Implementation
Synthesis of Evaluation
Analysis of Occupation (assessment/observation)
Intervention Plan
Step 1
Evaluation
Occupational Profile (interview)
Analysis of Occupation (assessment/observation)
Synthesis of Evaluation
Step 2
Intervention
Intervention Plan
Intervention Implementation
Intervention Review
Step 3
Outcomes
***GROUP QUESTION***
Characteristics of Good Documentation vs. Characteristics of Poor Documentation
Sort the following
- Is completed as soon as possible after service delivery
- Uses only layman's terminology
- Is succinct and clear
- Includes professional language that only an occupational therapist will understand
- Is truthful, even when the truth is undesired or inconvenient
- Is "therapist-centered" focusing on what the therapist did during the session
Characteristics of Good Documentation
- Is completed as soon as possible after service delivery
- Is succinct and clear
- Is truthful, even when the truth is undesired or inconvenient
Characteristics of Poor Documentation
- Uses only layman's terminology
- Includes professional language that only an occupational therapist will understand
- is "therapist-centered" focusing on what the therapist did during the session
Describe the difference between occupation as a means and occupation as an end.
Occupation as a means: The occupation is used to challenge underlying skills and factors; the "end product" is not the point.
Occupation as an end: Specific training/practice of the occupation; the "end product" of the occupation matters; quality and success in the occupation is the goal.
A client wants to live independently, but needs significant help to complete the IADL of "yard care."
If you were grading down using the IADL hierarchy of complexity, what would be an example of an "easier" IADL to work on during intervention?
Simple Meal Prep/Clean up
Basic Housekeeping
Laundry
Driving
Shopping
Heavy Cleaning
Yard Care
***GROUP QUESTION***
Articulate 2 reasons why the objective section should NOT only include a list of actions and assist levels?
- Does not reflect skilled services (only seems like you are observing)
- Occupation may not be emphasized
- Does not articulate the value of the intervention