AOTA NBCOT Exam Prep - Standards of Practice Questions
and Answers.
CARE Acronym for Documentation - Correct Answer a. Clarity
b. Accuracy
c. Relevance
d. Exceptions
COAST Acronym for Documentation - Correct 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? - Correct 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? - Correct 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? - Correct Answer Behavior of client, intervention provided,
response of client to intervention, plan for continued intervention
What is PIRP note format? - Correct Answer Purpose or reason for the intervention,
intervention provided, response of client to intervention, plan for continued intervention
What is SIRP note format? - Correct 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? - Correct
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? - Correct 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
What is the OASIS, in what setting is it administered, and a client who has what type of
insurance must have it administered? - Correct Answer - Outcome Assessment
Information Set (OASIS)
- Home health
- Medicare or Medicaid
What is the Family Educational Rights and Privacy Act of 1974? - Correct Answer
Identifies the confidentiality requirements of a student's educational record including OT
documentation completed on students
Who is the largest single payer of health care services in the United States - Correct
Answer CMS (Center for Medicare & Medicaid Services)
Who does Medicare cover? - Correct Answer - Most older adults 65+
- Some people with disabilities younger than 65 who have disabilities
- People who have end stage renal disease
What are the general requirements for OT reimbursement under Medicare? - Correct
Answer 1. A physician must provide a referral.
2. Services are provided following a written care plan that is approved and signed by the
physician.
3. Services are performed by qualified occupational therapy providers (OTRs or COTAs
under
appropriate supervision).
4. Services must be skilled and require the knowledge and expertise of occupational
therapy practitioners.
5. The amount, duration, and intensity of the services must be "reasonable and
necessary" for the client's condition
and Answers.
CARE Acronym for Documentation - Correct Answer a. Clarity
b. Accuracy
c. Relevance
d. Exceptions
COAST Acronym for Documentation - Correct 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? - Correct 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? - Correct 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? - Correct Answer Behavior of client, intervention provided,
response of client to intervention, plan for continued intervention
What is PIRP note format? - Correct Answer Purpose or reason for the intervention,
intervention provided, response of client to intervention, plan for continued intervention
What is SIRP note format? - Correct 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? - Correct
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? - Correct 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
What is the OASIS, in what setting is it administered, and a client who has what type of
insurance must have it administered? - Correct Answer - Outcome Assessment
Information Set (OASIS)
- Home health
- Medicare or Medicaid
What is the Family Educational Rights and Privacy Act of 1974? - Correct Answer
Identifies the confidentiality requirements of a student's educational record including OT
documentation completed on students
Who is the largest single payer of health care services in the United States - Correct
Answer CMS (Center for Medicare & Medicaid Services)
Who does Medicare cover? - Correct Answer - Most older adults 65+
- Some people with disabilities younger than 65 who have disabilities
- People who have end stage renal disease
What are the general requirements for OT reimbursement under Medicare? - Correct
Answer 1. A physician must provide a referral.
2. Services are provided following a written care plan that is approved and signed by the
physician.
3. Services are performed by qualified occupational therapy providers (OTRs or COTAs
under
appropriate supervision).
4. Services must be skilled and require the knowledge and expertise of occupational
therapy practitioners.
5. The amount, duration, and intensity of the services must be "reasonable and
necessary" for the client's condition
