AOTA NBCOT Exam Prep - Standards of Practice

CARE Acronym for Documentation - ANSWER-a. Clarity b. Accuracy c. Relevance d. Exceptions COAST Acronym for Documentation - ANSWER-• C: Client • O: Occupation (e.g., cut meat) • A: Assistance level (e.g., independently) • S: Specific conditions (e.g., using a rocker knife and an inner-lip plate) • T: Timeline What is a contact note? - ANSWER-- Typical note indicating contact with client, interventions used, clients response to intervention, instruction, training and education given, telephone calls / meetings - Nonattendance or missing an OT session is generally documented with a contact note What is DAP note format? - ANSWER-Similar to SOAP except that the S and O sections of the note are collapsed together in the D section What is BIRP note format? - ANSWER-Behavior of client, intervention provided, response of client to intervention, plan for continued intervention What is PIRP note format? - ANSWER-Purpose or reason for the intervention, intervention provided, response of client to intervention, plan for continued intervention What is SIRP note format? - ANSWER-Situation, intervention provided, response of client to intervention, plan for continued intervention What is the MDS (Minimal Data Set) and in what setting is it administered? - ANSWER-- Used to determine specific level of care needed - OTs may have to contribute to this in SNF setting What is the IRF-PAI and how does an OT contribute to it, and what setting is it administered in? - ANSWER-- The Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) - OT will contribute to it by scoring the client on the FIM - Administered in inpatient rehab