Documentation Flashcards
7 cards from real OTA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation flashcards as text
Under HIPAA, which of the following is an example of Protected Health Information (PHI)?
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.
An OTA wants to send a patient's evaluation summary to the referring physician. What must occur first?
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.
Which of the following best describes a functional outcome measure in OT documentation?
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.
How long are medical records typically required to be retained for adult patients under most state laws?
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.
An OTA documents that a patient achieved a goal before the target date. This information is most important for:
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.
Which of the following must be included in a discharge summary?
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.
Which of the following is the primary purpose of documenting skilled services in OT?
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.