Documentation Flashcards

Which documentation format uses a structured note divided into Subjective, Objective, Assessment, and Plan sections?

Answer: SOAP note

SOAP notes organize documentation into Subjective (patient report), Objective (measurable findings), Assessment (clinical interpretation), and Plan (treatment direction).

An OTA documents that a patient 'ambulated 50 feet with minimal assist.' This is an example of what type of documentation?

Answer: Objective data

Measurable, observable performance data such as distance walked and level of assist is objective documentation.

Which abbreviation is commonly used in OT documentation to indicate a patient requires no physical assistance?

Answer: Ind

'Ind' or 'I' stands for Independent, meaning the patient completes the task safely without any assistance.

When documenting a home program provided to a patient, the OTA should record:

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.

A patient states she is 'too tired to do therapy today.' How should the OTA document this?

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.

Which of the following is the most appropriate way to correct a handwritten documentation error?

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.

Which component is LEAST appropriate to include in daily treatment notes?

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.