OTA Documentation 2 — Questions and Answers
Question 1: Which documentation format uses a structured note divided into Subjective, Objective, Assessment, and Plan sections?
- DAP note
- SOAP note (Correct answer)
- BIRP note
- PIE note
Correct answer: SOAP note
SOAP notes organize documentation into Subjective (patient report), Objective (measurable findings), Assessment (clinical interpretation), and Plan (treatment direction).
Question 2: An OTA documents that a patient 'ambulated 50 feet with minimal assist.' This is an example of what type of documentation?
- Subjective data
- Objective data (Correct answer)
- Assessment data
- Goal data
Correct answer: Objective data
Measurable, observable performance data such as distance walked and level of assist is objective documentation.
Question 3: Which abbreviation is commonly used in OT documentation to indicate a patient requires no physical assistance?
- Min A
- Mod A
- CGA
- Ind (Correct answer)
Correct answer: Ind
'Ind' or 'I' stands for Independent, meaning the patient completes the task safely without any assistance.
Question 4: When documenting a home program provided to a patient, the OTA should record:
- Only the date the program was given
- The program instructions and patient/caregiver comprehension (Correct answer)
- That the OT supervised the home program delivery
- The cost of the home program materials
Correct answer: The program instructions and patient/caregiver comprehension
Documentation of a home program must include what was taught and evidence that the patient or caregiver demonstrated understanding.
Question 5: A patient states she is 'too tired to do therapy today.' How should the OTA document this?
- As objective data in the assessment section
- As subjective data, quoting the patient directly (Correct answer)
- As a plan modification only
- As a contraindication requiring physician contact
Correct answer: As subjective data, quoting the patient directly
Patient-reported feelings and statements are subjective data and should be documented using the patient's own words in quotation marks.
Question 6: Which of the following is the most appropriate way to correct a handwritten documentation error?
- Use correction fluid to cover the mistake
- Cross out with a single line, initial, and date (Correct answer)
- Erase the entry and rewrite it
- Write 'void' over the entire entry and start a new page
Correct answer: Cross out with a single line, initial, and date
The correct method is to draw a single line through the error, then add initials and date so the original entry remains legible.
Question 7: Which component is LEAST appropriate to include in daily treatment notes?
- Patient response to intervention
- Patient's insurance billing codes (Correct answer)
- Progress toward goals
- Any safety concerns observed
Correct answer: Patient's insurance billing codes
Billing codes are handled by billing departments and are not typically included within the narrative of daily treatment notes.
OTA Documentation 2
Which documentation format uses a structured note divided into Subjective, Objective, Assessment, and Plan sections?