occ 608 exam 1 Questions and Answers 100% Pass

occ 608 exam 1 Questions and Answers 100% Pass Medical record - Answer-legal and complete record of a patient's key clinical data and medical history Comprised of medical notes made by the healthcare team purpose of medical record - Answer-Ensures systematic documentation of a patient's medical history, diagnosis, treatment, and care components of a medical record - Answer-Chief complaint - what you really need to know History of present illness - when did symptoms start Physical examination Assessment and plan - further surgery plans?, diagnosis, treatment Order and prescriptions Progress notes Test results what to look for in a medical record for OT - Answer-pain levels vital signs lab values meds MD orders restrictions/precautions special learning needs other notes payer source discharge plan electronic health record education model - Answer-Basic computer literacy skills Health information literacy skills Clinical informatics skills EHR privacy and confidentiality skills Electronic data security skills EHR patient-centered communication skills domains of ot - Answer-Occupations Client Factors Performance Skills Performance Patterns Contexts occupations - Answer-adls iadls health management rest and sleep education work play leisure social participation contexts - Answer-environment factors personal factors performance patterns - Answer-habits routines roles rituals performance skills - Answer-observable, goal-directed actions motor skills process skills social interaction skills motor skills - Answer-moving oneself or moving and interacting with tangible task objects common terms: stabilizes, positions, reaches, manipulates, coordinates, transports, endures, paces process skills - Answer-selecting, interacting with, and using tangible task objects carrying out individual actions and steps preventing problems of occupational performance from occurring/reoccurring common terms: paces, attends, chooses, inquires, initiates, terminates, searches, organizes, notices, accommodates social interaction skills - Answer-communicating and interacting with others in the context of engaging in a personally and ecologically relevant daily life task performance that involves social interaction with others common terms: initiates, terminates, produces, physically supports, maintains flow, verbally supports, adapts *all terms in context of social interaction client factors - Answer-values, beliefs, spirituality, body functions, body structures body functions - Answer-physiological functions of body systems i.e. mental, sensory, cardiovascular, neuromuscular functions body structures - Answer-anatomical parts of the body such as organs, limbs, and their components purpose of an occupational profile - Answer-Summary of client's (persons, groups, populations) occupational history and experiences, patterns of daily living, interests, values, needs and relevant contexts components of occupational profile - Answer-why client is seeking services successes and barriers with occupatio