OTA Documentation 4 — Questions and Answers
Question 1: In electronic health records (EHR), which practice best protects patient confidentiality?
- Sharing login credentials with trusted colleagues for efficiency
- Logging out after each session and using unique passwords (Correct answer)
- Accessing records from a public Wi-Fi network with caution
- Printing records for personal reference and shredding when done
Correct answer: Logging out after each session and using unique passwords
Logging out after each session and maintaining unique passwords are essential EHR security practices that protect patient confidentiality.
Question 2: Which statement BEST describes the role of the OTA in the initial evaluation documentation?
- The OTA independently completes and signs the initial evaluation
- The OTA may contribute data but the OT is responsible for interpretation and the evaluation document (Correct answer)
- The OTA must complete the evaluation within 24 hours of the patient's admission
- The OTA and OT alternate responsibility for initial evaluations
Correct answer: The OTA may contribute data but the OT is responsible for interpretation and the evaluation document
Under the OT Practice Framework and state laws, the supervising OT is responsible for the evaluation and its interpretation; OTAs may contribute data collection.
Question 3: A physician's order reads 'OT evaluate and treat.' The OTA begins treatment. What should the OTA document first?
- The billing code for the first session
- A statement confirming OT supervision and the OT's evaluation findings (Correct answer)
- An independent assessment of the patient's deficits
- The patient's prior level of function from family interview
Correct answer: A statement confirming OT supervision and the OT's evaluation findings
The OTA must document that the supervising OT has completed the evaluation and established the plan of care before the OTA begins treatment.
Question 4: Which of the following is the best example of a measurable, functional short-term goal?
- Patient will improve upper extremity strength
- Patient will demonstrate improved motivation for self-care
- Patient will don shirt independently with adaptive equipment within 2 weeks (Correct answer)
- Patient will feel more confident in daily activities
Correct answer: Patient will don shirt independently with adaptive equipment within 2 weeks
A measurable goal specifies the task, the condition, the level of independence, and a time frame — 'don shirt independently with adaptive equipment within 2 weeks' meets all criteria.
Question 5: When the OTA upgrades a patient's assist level from 'moderate assist' to 'minimal assist,' this change should be:
- Reported verbally to the supervisor only
- Documented in the treatment note as evidence of progress (Correct answer)
- Held until the next formal reassessment period
- Noted in the patient's personal journal, not the medical record
Correct answer: Documented in the treatment note as evidence of progress
Changes in patient performance levels are clinically significant and must be documented in treatment notes to justify continued skilled care.
Question 6: An OTA documents an intervention that was not actually performed. This action constitutes:
- A minor charting omission
- Healthcare fraud (Correct answer)
- An acceptable practice if the intervention was planned
- A documentation shortcut permitted during high-census periods
Correct answer: Healthcare fraud
Documenting services not rendered is considered healthcare fraud and is illegal, regardless of intent or staffing pressures.
Question 7: Which term describes the set of standards that specify what information must be included in OT documentation for Medicare reimbursement?
- ICD-10 coding requirements
- Medicare Coverage Policies and Local Coverage Determinations (LCDs) (Correct answer)
- ADA documentation standards
- OSHA charting requirements
Correct answer: Medicare Coverage Policies and Local Coverage Determinations (LCDs)
Medicare's Local Coverage Determinations (LCDs) and national coverage policies specify what documentation elements are required for OT services to be reimbursed.
OTA Documentation 4
In electronic health records (EHR), which practice best protects patient confidentiality?