OTA Documentation 3 — Questions and Answers
Question 1: Under HIPAA, which of the following is an example of Protected Health Information (PHI)?
- A patient's therapy diagnosis without any identifying information
- A patient's name combined with their diagnosis and treatment dates (Correct answer)
- Aggregate therapy outcome statistics with no names
- General facility policies posted in the waiting room
Correct answer: A patient's name combined with their diagnosis and treatment dates
PHI includes any individually identifiable health information, such as a patient's name paired with diagnosis or treatment details.
Question 2: An OTA wants to send a patient's evaluation summary to the referring physician. What must occur first?
- The OT supervisor must co-sign the summary
- A signed patient authorization or a HIPAA-permitted disclosure must be in place (Correct answer)
- The facility billing department must approve the release
- The patient's family must be notified
Correct answer: A signed patient authorization or a HIPAA-permitted disclosure must be in place
Releasing health information requires either a signed patient authorization or a HIPAA-permitted purpose such as treatment coordination.
Question 3: Which of the following best describes a functional outcome measure in OT documentation?
- A score on a muscle strength test
- The patient's ability to perform meaningful daily activities (Correct answer)
- The number of therapy sessions attended
- The therapist's subjective impression of improvement
Correct answer: The patient's ability to perform meaningful daily activities
Functional outcome measures assess how well a patient can perform meaningful occupational activities such as dressing, cooking, or work tasks.
Question 4: How long are medical records typically required to be retained for adult patients under most state laws?
- 1 year
- 3 years
- 7–10 years (Correct answer)
- Indefinitely
Correct answer: 7–10 years
Most states require adult medical records to be retained for a minimum of 7–10 years, though specific requirements vary by state.
Question 5: An OTA documents that a patient achieved a goal before the target date. This information is most important for:
- Discontinuing therapy immediately
- Reassessing and updating goals to reflect continued progress (Correct answer)
- Requesting an extension of the therapy authorization
- Filing a discharge summary without further assessment
Correct answer: Reassessing and updating goals to reflect continued progress
When a goal is met early, the OTA should collaborate with the supervising OT to reassess and establish new, more challenging goals.
Question 6: Which of the following must be included in a discharge summary?
- A list of all staff who treated the patient
- Patient's status at discharge, goals met, and recommendations for follow-up (Correct answer)
- The patient's full insurance coverage details
- A comparison of the facility's outcomes to national benchmarks
Correct answer: Patient's status at discharge, goals met, and recommendations for follow-up
A discharge summary should document the patient's functional status at discharge, which goals were achieved, and any recommendations for continued care.
Question 7: Which of the following is the primary purpose of documenting skilled services in OT?
- To justify reimbursement and demonstrate medical necessity (Correct answer)
- To track the therapist's productivity metrics
- To satisfy state licensure renewal requirements
- To provide data for facility marketing materials
Correct answer: To justify reimbursement and demonstrate medical necessity
Documenting skilled services demonstrates medical necessity, which is required for insurance reimbursement and legal justification of OT services.
OTA Documentation 3
Under HIPAA, which of the following is an example of Protected Health Information (PHI)?