Documentation for the OTA, SOAP Notes The OTA guide – Flashcards
Unlock all answers in this set
Unlock answersquestion
HIPPA
answer
Health Insurance Portability and Accountancy Act
question
SOAP
answer
Subjective, Objective, Assessment, Plan
question
Independent (I)
answer
Performs task on their own .
question
Modified Independence (Mod I)
answer
Performs task independently with a device
question
Set up only
answer
Set up the patient & leave the area
question
Supervision (S)
answer
Performs the task but with visual supervision
question
Contact Guard ( CG)
answer
****Also known as standby assist***just touching the patient
question
Minimal assistance (Min A)
answer
Requires assistance approximately 25% of the time
question
Moderate assistance ( Mod A)
answer
Requires assistance approximately 50% of the time
question
Maximum assistance ( Max A)
answer
Requires assistance approximately 75% of the time
question
Total Assistance
answer
Dependent with task completion ( you are giving 100 % assistance)
question
Abd `
answer
abduction
question
Add
answer
adduction
question
ADD
answer
attention deficit disorder
question
AFO
answer
ankle foot orthosis
question
AKA
answer
above knee amputation
question
ALS
answer
Amyotrophic Lateral Sclerosis
question
AMB
answer
ambulation; to walk or gait
question
AROM
answer
active range of motion - no assistance
question
c w/line above it
answer
with
question
subjective
answer
anything pt states or family members, medical staff has stated about the pt
question
objective
answer
anything measurable, anything pt did, pain scale, what type assistance needed ex: mid, mod, ect; ROM measurement
question
assessment
answer
How the pt's occupational performance is affected, stating your professional opinion.
question
plan
answer
The goals for the pt
question
Example of assessment
answer
* Explaining the "O", giving your opinion. * Document any type of improvement * your professional opinion
question
Example of plan
answer
* 1.) Consumers will continue prevocational program 5 days/week in order to increase task behaviors for work. 2.) Consumer will independently punch time care with one verbal cue by the end of next treatment session
question
example of subjective
answer
* " I can't tie my shoes or zip my coat." * Resident reports pain in the (R) hand when using computer keyboard * Pt expresses doubts about ever getting better
question
Example of plan
answer
Consumer to be seen for 2 more weeks for 60 min. twice weekly sessions for skilled instruction in performing IADL. By anticipated discharge on 9/13/09, consumer will be able to independently mange all laundry tasks at Laundromat.
question
Example of objective
answer
Pt. seen 1 hour in OT clinic for fabrication of thumb spica splint to decrease thumb pain during ADL
question
Therapeutic Procedure
answer
Also known as therapeutic exercise ***15 increments (see someone for 30 min, bill for 2 increments ) *** helps build strength endurance *** ROM & flexibility
question
Neuromuscular re education
answer
***15 min increments *** works on coordination, balance, movement, kinesthetic sense, posture /proprioception during sitting/standing exercises
question
Therapeutic activity
answer
Direct one on one patient *** 15 min increments *** uses activities to improve functional performance *** more money for this code
question
Self care/ home management
answer
ADL's are billed under this ****ADL's training, meal preparation, safety procedures, instruction in using assistive technology ( iPad, reaches)
question
IDEA
answer
Individuals with Disabilities Act ***for children up to 22yrs old *** therapy that is paid for children to have services in school
question
What are 3 different types of payers
answer
Pt. - 1st party payor Provider - 2nd party payor Ins Co. - 3rd party payor
question
What can't we bill for
answer
Hot pads & documentation
question
3rd party payor
answer
Anybody that is paying for that insurance ** ex: Medicare, Medicaid, BC/BS
question
CPT
answer
Current Procedural Terminology ***treatment codes
question
ICD-9
answer
International Classification of Diseases
question
Key words to determine assessment
answer
Hinders, may, appear
question
RUG
answer
Rehab Utilization Group *How we are reimbursed based on the scoring we are given
question
When can you bill for documentation ?
answer
If you document while you are treating the pt
question
Occupational profile
answer
* interviewing the pt * analyze occupational performance
question
How do you correct an error?
answer
* draw a line through it * write error * initial * date it
question
Largest reinbursers for health care services
answer
Medicare & Medicaid
question
What is CMS?
answer
Centers for Medicaid & Medicare Services * overseas Medicare & Medicaid
question
Beneficence
answer
Demonstrate a concern for the well being of the recipients of their services
question
Which core value is equal to beneficence
answer
Altruism
question
Nonmaleficence
answer
OT personnel shall take precautions to avoid inflicting or imposing harm
question
Which core value is equal to Nonmaleficence
answer
Prudence
question
Autonomy & Confidentiality
answer
OT personnel shall respect the rights of the patient
question
Which core value is equal to Autonomy & Confidentiality
answer
Dignity & Freedom
question
Social justice
answer
OT personnel shall provide services in a fair and equitable manner
question
Which core value is equal to social justice
answer
Equality
question
Procedural justice
answer
OT personnel shall comply with laws and policies
question
Which core value is equal to procedural justice?
answer
Justice
question
Veracity
answer
OT personnel shall provide accurate information
question
Which core value is equal to veracity ?
answer
Truth
question
RUG
answer
Rehab Utilization Group * How we are reimbursed
question
Fidelity
answer
OT personnel shall treat colleagues and other professionals with fairness, discretion and integrity
question
Which core value is equal to fidelity ?
answer
Prudence & Equality
question
Altruism
answer
Unselfish concern for the welfare of others
question
Equality
answer
All individuals have the same human right and opportunities
question
Freedom
answer
The individual is allowed to exercise choice and to demonstrate independence, initiative and self direction
question
Justice
answer
Places value on moral and legal principles as fairness, equity, truthfulness and objectivity
question
Dignity
answer
Emphasizes the importance of valuing the uniqueness of each person
question
Truth
answer
To be faithful to facts and reality
question
Prudence
answer
Is the ability to govern and discipline oneself through reason
question
What are the 4 standards of practice?
answer
* Standard I - Professional Standing and Responsibility * Standard II - Screening, Evaluation and Re-evaluation * Standard III - Intervention * Standard IV - Outcomes
question
What are the 4 CPT codes that are used for billing OT services
answer
* Therapeutic Procedure * Neuromuscular re-education * Therapeutic activity * Self care/Home management
question
3 steps for service delivery process?
answer
** advocacy ** direct services ** consultation
question
3 steps of occupational therapy process
answer
** evaluation ** intervention ** targeting of outcome
question
2 things that are done during the evaluation
answer
** occupational profile ** analysis of occupational performance
question
4 parts of intervention process
answer
** intervention planning ** intervention implementation ** intervention review ** outcomes
question
Treatment goals, looking ahead to discharge needs & referrals are done here
answer
Intervention planning
question
Should be done every session
answer
Intervention review
question
Done after they have been discharged, have they or have they not reached their goals
answer
Outcomes
question
Standard I
answer
Professional standing & responsibility
question
Standard II
answer
Screening, Evaluation & Re evaluation
question
Standard III
answer
Intervention
question
Standard IV
answer
Outcomes
question
Closest to procedural justice, maintains licensure, accreditation & following rules
answer
Standard I
question
OTR responsible for all of this, OTA can do screening
answer
Standard II
question
OTA's carry this out
answer
Standard III
question
Goals; did they or didn't they meet them
answer
Standard IV
