Documentation Basics
Name three essential elements that every OT note must include according to the guidelines.
ACOTE alignment: Professional behavior & documentation
Date; time of service/duration (minutes); clinician first and last name with required credentials; services; what was said and happened; reflect skilled OT services
Host Note: ACOTE Alignment: Professional behavior. Accept equivalent phrasing.
Clue: List two reasons documentation is important per the uploaded document.
ACOTE alignment: Professional ethics & legal responsibilities
Answer: Protects against litigation; forms impression of professional competence; used for reimbursement review.
Host Note: Also accept: Clients may read records; records inform other professionals.
Clue: What is "baseline data" and why is it necessary?
ACOTE alignment: Clinical reasoning & outcomes
Answer: Client's starting level of function; necessary to measure progress and justify skilled services.
Host Note: Examples: ROM degrees, independence level, pain score.
Clue: Name three precautions the document lists for electronic documentation security.
ACOTE alignment: Safety & confidentiality
Answer: Do not share username/password; log out when leaving workstation; do not access EHRs without a direct need-to-know; be aware of employers' safeguards, including transmission of personal health information via email.
Clue: Give examples of "special situations" that warrant documentation beyond routine notes.
ACOTE alignment: Safety reporting & incident documentation
Answer: Change in client status, missed visit, lack of compliance, incident reports.
When documenting, always assume others will be reading your records. Who might this be?
ACOTE alignment: Clinical documentation & intervention planning
Client, supervisors, reimbursement parties.
Clue: What principle should be used in language when documenting incidents or client conditions?
ACOTE alignment: Professionalism & ethics
Answer: Use person-first language; be objective, concise, and nonjudgmental.
Host Note: Discourage subjective or stigmatizing language.
Clue: List components that should be included when documenting goals of intervention and outcomes.
ACOTE alignment: Outcomes documentation & clinical reasoning
Answer: Goals, baseline data, plan description, implementation details, and outcomes.
Host Note: Stress measurable goals and timelines where possible.
Clue: What should you do with your workstation credentials and when you leave a workstation?
ACOTE alignment: Privacy & professional responsibilities
Answer: Do not share credentials and log out when leaving.
Host Note: Emphasize session lockouts and two-factor authentication if used.
Clue: What is the purpose of incident reports according to the document? List three goals.
ACOTE alignment: Quality improvement & incident reporting
Answer: Ensure optimal care provided; legal protection; identify need for staff training.
Host Note: Also include administrative follow-up.
When you make a documentation error, how would you correctly fix it? (print and electronic)
ACOTE alignment: Documentation accuracy & clarity
Non-erasable, waterproof ink
Stike error
Write addendum
Ensure all data is present
Clue: What administrative data should be included in an incident report? Provide at least four items.
ACOTE alignment: Administrative documentation & reporting
Answer: Name, address, DOB, incident date/location, patient diagnosis, summary of care, type of incident.
Host Note: Accept any four or more items listed.
Clue: Give two examples of measurable ways to document client reaction during a therapeutic session.
ACOTE alignment: Client-centered documentation & progress
Answer: Number of repetitions completed; pain rating before/after; time to complete task; level of assistance (e.g., 2/5 cues).
Host Note: Reward answers that include objective measures (numbers).
Clue: Describe one example of an EHR-related documentation error and how to avoid it.
ACOTE alignment: Documentation accuracy & EHR best practices
Answer: Misusing quotation marks (quoting paraphrase); avoid by using quotes only for verbatim client statements.
Host Note: Other errors include wrong patient selection (verify ID).
Clue: When documenting, what tone and perspective should the entry maintain?
ACOTE alignment: Professional communication & documentation tone
Answer: Objective, concise, person-first language, factual course of action.
Host Note: Avoid editorializing or speculation.
Clue: ID common documentation errors.
ACOTE alignment: Clinical reasoning & professional documentation
Answer: Verb tense, plural vs possessive, pronouns, spelling
Clue: For documentation to support reimbursement review, what four elements should be clearly present?
ACOTE alignment: Reimbursement & justification
Answer: Skilled OT services; time/duration; functional outcome/justification; specific interventions performed.
Host Note: Require measurable functional improvement and relation to skilled services.
Clue: Explain how documentation demonstrates "skilled occupational therapy services" — give two specific documentation phrases.
ACOTE alignment: Skilled services rationale
Answer: "Therapist provided clinical reasoning to grade task demands due to safety risk" OR "Therapist performed assessment requiring specialized knowledge."
Host Note: Encourage specificity linking interventions to clinical reasoning.
Clue: Explain why accessing EHRs without a direct need-to-know is cautioned against and give one potential consequence.
ACOTE alignment: Confidentiality & legal consequences
Answer: Unauthorized access breaches privacy/confidentiality; consequence: disciplinary action, legal/HIPAA violations.
Clue: You supervise an OT student and a COTA. documents a session. What must be added to their documentation notes?
ACOTE alignment: Supervision & documentation policy
Host Note: Must include supervisor credentials and timely co-signature.