Documentation and Service Management Flashcards

Which of the following is an example of an occupational therapy short-term goal?

Answer: Client will don a shirt with modified independence using buttonhook in 2 weeks

Short-term goals should be specific, measurable, include a time frame, and address a discrete skill or step toward the long-term goal.

Supervision of a COTA by an OTR should be documented to reflect:

Answer: The frequency, type, and content of supervision provided

COTA supervision documentation should reflect the frequency, nature, and content of supervisory interactions to meet state licensure and accreditation requirements.

A therapist realizes they made an error in a written progress note. The correct action is to:

Answer: Draw a single line through the error, write 'error', date, and initial it

The correct method for correcting a written documentation error is to draw a single line through it, note 'error', and add the date and initials to maintain transparency.

In value-based care models, OT outcomes are most effectively measured by:

Answer: Functional improvement, goal attainment, and return to meaningful occupations

Value-based care rewards measurable functional outcomes, goal achievement, and return to meaningful occupational roles over volume of services provided.

Which billing unit in outpatient OT under Medicare represents 15 minutes of skilled service?

Answer: 1 therapy unit (timed code)

Medicare outpatient therapy uses time-based billing where most therapeutic procedure codes are billed in 15-minute timed units.

An OT determines that a client no longer requires skilled OT services. Discharge criteria include:

Answer: Client has reached maximum therapeutic benefit or goals are achieved

Discharge is clinically indicated when the client has achieved goals, reached maximum therapeutic benefit, or when continued skilled services are no longer medically necessary.