Prep Study Documentation Exam
Questions & Answers 2024/2025
What does SOAP mean? - ANSWERSsubjective, objective, assessment, plan
Subjective? - ANSWERS-Things client says to OT
"After my stroke, my R hand is tight in the morning"
"Pt reported she had difficulty sleeping and expressed problems with spasticity"
-Or you can use direct quotes from the pt in your notes
-Pain level
-Brief - (1-2 sentences) does not want 3 paragraphs
Objective? - ANSWERS-Numbers and description of the level of assistance.
"Pt was able to transfer from bed to wheelchair with moderate assistance" - you're writing about what
they can do
Assessment? - ANSWERS**This is why we get paid good money - important!!**
-We need to try to assess what the objective info was - are they improving?
-Exercise clinical reasoning
-Functional problem list
-Consider long-term goal
-Address problems and potentials and progress
-Put the pt rehab potential
Ex: If we put "fair potential" insurance may not want to pay
Plan? - ANSWERS-What you're gonna do next, how long you'll be seeing the pt for
-Progress note, referral to SPT for _____
,HIPAA (Health Insurance Portability and Accountability Act)? - ANSWERS-We have a responsibility to
protect their information
-They have the right to view our documentation, read it, and have a copy of it
PHI (Protected Health Information) - ANSWERS-Make sure you log off the computer, not sharing a
password with anyone
-Don't write pt info on post-it notes
-It is okay to share with a mentor, almost like a consult.
-Justify why you're accessing information.
-Don't share exciting new pt you have with coworkers at lunch
-Emailing - needs to be encrypted
-Texting is not secure, abide by facility guidelines
FERPA (Family Educational Rights and Privacy Act) - ANSWERSSchool-based setting/system
Can not share info unless it has been released
Why do we document? - ANSWERS-Client Care Management
-Reimbursement
-Utilization Review and Management
-Legal
-Quality Management
-Accreditation
-Education and Research
-Business Development and Management
-Client Access
Why is reimbursement important? - ANSWERS-Describe the treatment plan to meet the requirement for
billing
-Make sure tx was worth the payment
-Need to make money for the employer
, Why is utilizing review and management important? - ANSWERSAsk questions, like: What can we learn
from reviewing the charts?
Why is documentation legal? - ANSWERSProtocol of facility
Medicare (MCR) Reimbursement? - ANSWERS--A federal program for people 65+
-Other people that aren't 65+ qualify i.e: end-stage renal disease, or sometimes veterans #funfacts
Part A: inpatient, SNF, home health, and hospice
Part B: outpatient, some long term care, therapy cap is no longer in use, but the book still talks about it
Part C: Medicare advantage plan: secondary insurances that cover the 20% that MCR doesn't cover
Part D: prescription plan that the pt has to pay extra for
Medicaid and Children's Health Insurance Plan (CHIP)? - ANSWERS-Federal and state program
-Very low-income families and their children
-Some states have better benefits than others
Private Insurance? - ANSWERSWhere you get your benefits from your employer
-Premiums: (Can put spouse and children)
-Deductibles: out of pocket (OOP)
Important to know what you're going to do for your patient
Better benefits (in network/ out of network)
Worker's Compensation? - ANSWERSWhat employees get if they're injured on the job.
Schools and reimbursement? - ANSWERS-Required to provide for students.
-Ages 3-21
Early Intervention Programs? - ANSWERSHave their own set of documentation
Questions & Answers 2024/2025
What does SOAP mean? - ANSWERSsubjective, objective, assessment, plan
Subjective? - ANSWERS-Things client says to OT
"After my stroke, my R hand is tight in the morning"
"Pt reported she had difficulty sleeping and expressed problems with spasticity"
-Or you can use direct quotes from the pt in your notes
-Pain level
-Brief - (1-2 sentences) does not want 3 paragraphs
Objective? - ANSWERS-Numbers and description of the level of assistance.
"Pt was able to transfer from bed to wheelchair with moderate assistance" - you're writing about what
they can do
Assessment? - ANSWERS**This is why we get paid good money - important!!**
-We need to try to assess what the objective info was - are they improving?
-Exercise clinical reasoning
-Functional problem list
-Consider long-term goal
-Address problems and potentials and progress
-Put the pt rehab potential
Ex: If we put "fair potential" insurance may not want to pay
Plan? - ANSWERS-What you're gonna do next, how long you'll be seeing the pt for
-Progress note, referral to SPT for _____
,HIPAA (Health Insurance Portability and Accountability Act)? - ANSWERS-We have a responsibility to
protect their information
-They have the right to view our documentation, read it, and have a copy of it
PHI (Protected Health Information) - ANSWERS-Make sure you log off the computer, not sharing a
password with anyone
-Don't write pt info on post-it notes
-It is okay to share with a mentor, almost like a consult.
-Justify why you're accessing information.
-Don't share exciting new pt you have with coworkers at lunch
-Emailing - needs to be encrypted
-Texting is not secure, abide by facility guidelines
FERPA (Family Educational Rights and Privacy Act) - ANSWERSSchool-based setting/system
Can not share info unless it has been released
Why do we document? - ANSWERS-Client Care Management
-Reimbursement
-Utilization Review and Management
-Legal
-Quality Management
-Accreditation
-Education and Research
-Business Development and Management
-Client Access
Why is reimbursement important? - ANSWERS-Describe the treatment plan to meet the requirement for
billing
-Make sure tx was worth the payment
-Need to make money for the employer
, Why is utilizing review and management important? - ANSWERSAsk questions, like: What can we learn
from reviewing the charts?
Why is documentation legal? - ANSWERSProtocol of facility
Medicare (MCR) Reimbursement? - ANSWERS--A federal program for people 65+
-Other people that aren't 65+ qualify i.e: end-stage renal disease, or sometimes veterans #funfacts
Part A: inpatient, SNF, home health, and hospice
Part B: outpatient, some long term care, therapy cap is no longer in use, but the book still talks about it
Part C: Medicare advantage plan: secondary insurances that cover the 20% that MCR doesn't cover
Part D: prescription plan that the pt has to pay extra for
Medicaid and Children's Health Insurance Plan (CHIP)? - ANSWERS-Federal and state program
-Very low-income families and their children
-Some states have better benefits than others
Private Insurance? - ANSWERSWhere you get your benefits from your employer
-Premiums: (Can put spouse and children)
-Deductibles: out of pocket (OOP)
Important to know what you're going to do for your patient
Better benefits (in network/ out of network)
Worker's Compensation? - ANSWERSWhat employees get if they're injured on the job.
Schools and reimbursement? - ANSWERS-Required to provide for students.
-Ages 3-21
Early Intervention Programs? - ANSWERSHave their own set of documentation
