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DOCUMENTATION
DOCUMENTATION W/ CARE
GOAL DIRECTION
GOAL WRITING FORMAT
INTERVENTION
100
WHAT SHOULD BE ON EVERY PAGE OF DOCUMENTATION?
What is FULL NAME AND CASE NUMBER
100
DOCUMENTING W/ CARE WHAT DO THE LETTERS STAND FOR?
What is CLARITY, ACCURACY, RELEVANCE, EXCEPTIONS
100
PRIMARY RESPONSIBILITY OF OTR, BUT OTA MAY CONTRIBUTE TO THE PROCESS. YOU NEED CLIENT COLLABORATION OR CLIENT'S CAREGIVE AND GUARDIAN COLLABORATION
What is ROLE DELINEATION
100
WHAT DOES ABCD STAND FOR IN GOAL WRITING
What is AUDIENCE= CLIENT BEHAVIOR=OBSERVABLE CONDITION=UNDER WHAT CIRCUMSTANCE DEGREE= MEASUREABLE PART
100
BASED OFF OF AOTA WHAT ARE 5 INTERVENTION APPROACHES
What is CREATE/PROMOTE ESTABLISH/RESTORE MAINTAIN MODIFY PREVENT
200
This color pen should be used for documentation. (ABSOLUTELY NO PENCIL)
What is BLACK PEN
200
to describe the client's level of performance, to predict future functions of the client, to measure the outcomes of OT intervention. *Describe client's situation, predict future function, and establish baseline functional performance
What is an Evaluation Report
200
6 TYPES OF OUTCOMES WHEN WRITING A GOAL
What is OCCUPATIONAL PERFORMANCE, CLIENT SATISFACTION, ROLE COMPETENCE, ADAPTIATION, HEALTH AND WELLNESS, QUALITY OF LIFE
200
WHAT DOES THE ABBREVIATION FEAST STAND FOR?
What is FUNCTION=AREA OF OCCUPATIONAL PERFORMANCE EXPECTIATION= 'THE CLIENT WILL' ACTION= VERB SPECIFIC CONDITION= UNDER WHAT CIRCUMSTANCE TIMELINE= WHEN THE GOAL WILL BE COMPLETE
200
NAME ATLEAST 3 OUTCOMES THAT MAY OCCUR AFTER INTERVENTION
What is IMPROVED OCCUPATIONAL PERFORMANCE ADAPTATION ROLE COMPETENCE IMPROVED HEALTH AND WELLNESS PREVENTION OF FURTHER DIFFULTIES IMPROVED QUALITY OF LIFE SELF-ADVOCACY OCCUPATIONAL JUSTICE
300
In documentation what element involves following federal and state laws while also following facility and agency polices? Ex: shredding documents (3 different ones)
What is record disposal, record storage, and confidentiality
300
NAME THE 5 STEPS THAT HAVE TO BE FOLLOWED FOR REIMBURSEMENT TO TAKE PLACE?
What is THE NECESSITY FOR OCCUPATIONAL THERAPY SERVICES MUST BE DOCUMENTED, OT SCOPE OF PRACTICE MUST BE ADHERED TO, MUST BE CLEAR THAT ONLY AN OCCUPATIONAL THERAPIST WOULD BE ABLE TO PROVIDE THIS INTERVENTION, GOALS MUST BE ADDRESSED, DIFFERENT PAYER SOURCES, DIFFERENT GUIDELINES
300
NAME 6 DIFFERENTTYPES OF GOALS
What is RESTORATIVE GOALS, HABILITATIVE GOALS, MAINTENANCE GOALS, MODIFICATION GOALS, PREVENTATIVE GOALS, HEALTH PROMOTION
300
WHAT DOES THE ABBREVIATION RHUMBA PERTAIN TO
What is RELEVANTS/RELATES HOW LONG UNDERSTANDABLE MEASUREABLE BEHAVIORAL ACHIEVABLE
300
WHAT SHOULD YOU CONSIDER WHEN SUMMARIZING PROGRESS
What is CHOOSE YOUR WORDS CAREFULLY CONSIDER OTHER'S INTERPRETATION OF WORD FOCUS ON FUNCTION AND PROGRESS TOWARD GOALS REVISE GOALS IF NECESSARY
400
using what type of guideline would an employee have to follow professional standards, follow facility or agency policies?
What is technology
400
SPECIFIC PERIOD OF TIME, LEAD UP TO LONG TERM GOALS
What is SHORT TERM GOALS
400
WHAT DOES SMART STAND FOR?
What is SIGNIFICANT=WILL IT MAKE A DIFFERENCE IN THE PERSON'S LIFE MEASURABLE-CLEAR IN HOW YOU WILL DETERMINE IT IS ACHIEVED RELATED=CLEAR CONNECTION TO EVAL TIME LIMITED=BY WHEN
400
TYPES OF INTERVENTION NOTES
What is SOAP NOTES, DAP, NARRATIVE, PROGRESS, FLOW SHEETS, ATTENDANCE LOGS
500
client identification, date and type of contact, type, signature, placement of signature, countersignature, terminology, abbreviations, corrections, technology, confidentiality, record storage
What is the 13 elements that must be present in documentation
500
NAME A FEW STEPS USED FOR THE EVALUATION PROCESS
What is synthesizing information from the occupational profile, selecting the appropriate occupational therapy theories, observing occupational performance and obtaining information, selecting and measuring contexts, activity demands, and client factors, interpreting assessment data, hypothesis generating, goal setting, confirming the outcome measures, delegating intervention approaches
500
IN WHAT TYPE OF GOAL DO YOU HAVE TO BE CONCERNED WITH THIRD PAYER REIMBURSEMENT? *IT MAY BE SEEN AS PROGRESS NOT BEING MADE
What is MAINTENANCE GOALS
500
NAME THE FOUR TYPE OF GOAL WRITING FORMATS
What is ABCD FEAST RHUMBA SMART
500
WHAT DOES SOAP STAND FOR? WHAT DOES DAP STAND FOR?
What is S=SUBJECTIVE WHAT THE CLIENT SAID/REPAOTED THAT IS SIGNIFICANT, O=OBJECTIVE- MEASURABLE DATA, A=ASSESSMENT WHAT DOES THIS ALL MEAN?, P=PLAN WHAT IS THE PLAN OF CARE? D=DESCRIPTION MUCH LIKE COMBINATION OF S AND O FROM SOAP FORMAT A=ASSESSMENT P=PLAN