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
In electronic health records (EHR), which practice best protects patient confidentiality?
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.
Which statement BEST describes the role of the OTA in the initial evaluation documentation?
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.
A physician's order reads 'OT evaluate and treat.' The OTA begins treatment. What should the OTA document first?
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.
Which of the following is the best example of a measurable, functional short-term goal?
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.
When the OTA upgrades a patient's assist level from 'moderate assist' to 'minimal assist,' this change should be:
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.
An OTA documents an intervention that was not actually performed. This action constitutes:
Answer: Healthcare fraud
Documenting services not rendered is considered healthcare fraud and is illegal, regardless of intent or staffing pressures.
Which term describes the set of standards that specify what information must be included in OT documentation for Medicare reimbursement?
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.