Documentation exam 1 with correct detailed
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answers
WHO |do |we |document |for? |- |✔✔We |document |for |multiple |audiences |including
* |intervention |team
* |client |and |surrogates |(caregivers/family/guardians)
* |facility |management |personel
* |third-party |payers
* |accreditation |surveyors
* |lawyers
Services |provided |and |
Paint |a |verbal |picture |for |the |reader
Document |plan |for |- |✔✔Services |provided |and |how |the |client |responded |to |it |
Paint |a |verbal |picture |for |the |reader
Document |plan |for |the |clients |progression |to |work |towards |goals |small |summery |of |session.
When |do |we |document? |- |✔✔As |close |to |session |as |possible |frequency |and |format |dictated |by |
facility.
What |does |hippa |stand |for |- |✔✔Health |insurance |portability |and |accountability |act |of |1996
What |does |HIPPA |protect? |- |✔✔All |communication |related |to |client |care
What |code |of |ethics |does |HIPPA |fall |under |? |- |✔✔Confidentiality |- |Principle |3: |Autonomy |and
|Occupational |therapy |personnel |shall |respect |the |right |of |the |individual |to |self-determination, |
privacy, |confidentiality, |and |consent.
, What |falls |under |protected |health |information? |- |✔✔PROTECTED |HEALTH |INFORMATION |
1.Patient |name
2.Patient |address
3.Any |date |which |could |identify |the |individual
4.Any |number |which |could |identify |the |individual
5.Photographs
Whith |hippa |in |mind |what |info |can |be |used |safely |to |talk |about |PT? |- |✔✔Age |(but |not |if |over |90 |y/o)
•Race, |Ethnicity, |Marital |Status, |Identified |Gender
•Diagnosis, |Reason |for |admission, |Condition |upon |d/c
•Course |of |treatment, |Response |to |intervention
•Name/location |of |facility
•Codes
What |are |some |goal |formats |we |use |in |OT? |- |✔✔Formats |for |Goal |Writing
|
ABCD
COAST
FEAST
RHUMBA
SMART
Represent |the |final |product |of |the |therapeutic |intervention/guide |the |intervention |to |a |conclusion
•Are |set |before |the |short- |term |goals
•Often |determine |the |time |to |discontinue |therapy
•Could |be |known |as |discharge |goals |or |outcome |goals |- |✔✔Long |term |GoAL
•Based |on |the |long- |term |goals
| | | | | |
answers
WHO |do |we |document |for? |- |✔✔We |document |for |multiple |audiences |including
* |intervention |team
* |client |and |surrogates |(caregivers/family/guardians)
* |facility |management |personel
* |third-party |payers
* |accreditation |surveyors
* |lawyers
Services |provided |and |
Paint |a |verbal |picture |for |the |reader
Document |plan |for |- |✔✔Services |provided |and |how |the |client |responded |to |it |
Paint |a |verbal |picture |for |the |reader
Document |plan |for |the |clients |progression |to |work |towards |goals |small |summery |of |session.
When |do |we |document? |- |✔✔As |close |to |session |as |possible |frequency |and |format |dictated |by |
facility.
What |does |hippa |stand |for |- |✔✔Health |insurance |portability |and |accountability |act |of |1996
What |does |HIPPA |protect? |- |✔✔All |communication |related |to |client |care
What |code |of |ethics |does |HIPPA |fall |under |? |- |✔✔Confidentiality |- |Principle |3: |Autonomy |and
|Occupational |therapy |personnel |shall |respect |the |right |of |the |individual |to |self-determination, |
privacy, |confidentiality, |and |consent.
, What |falls |under |protected |health |information? |- |✔✔PROTECTED |HEALTH |INFORMATION |
1.Patient |name
2.Patient |address
3.Any |date |which |could |identify |the |individual
4.Any |number |which |could |identify |the |individual
5.Photographs
Whith |hippa |in |mind |what |info |can |be |used |safely |to |talk |about |PT? |- |✔✔Age |(but |not |if |over |90 |y/o)
•Race, |Ethnicity, |Marital |Status, |Identified |Gender
•Diagnosis, |Reason |for |admission, |Condition |upon |d/c
•Course |of |treatment, |Response |to |intervention
•Name/location |of |facility
•Codes
What |are |some |goal |formats |we |use |in |OT? |- |✔✔Formats |for |Goal |Writing
|
ABCD
COAST
FEAST
RHUMBA
SMART
Represent |the |final |product |of |the |therapeutic |intervention/guide |the |intervention |to |a |conclusion
•Are |set |before |the |short- |term |goals
•Often |determine |the |time |to |discontinue |therapy
•Could |be |known |as |discharge |goals |or |outcome |goals |- |✔✔Long |term |GoAL
•Based |on |the |long- |term |goals
