OTA 110 Unit 4 Exam Questions And Answers (Updated And Verified)

OTA 110 Unit 4 Exam Questions And Answers (Updated And Verified) Purpose of documentation - answercommunicates client care management, written for re- imbursement, reflect OT practitioner's clinical reasoning and professional judgement, quality improvement Readers of documents - answercourt officials within the legal system, researchers, funding sources, client Why document? - answerfor someone else to read and understand, funding source to pay, client has the right to read, defend against malpractice Essential Content for notes - answerfocus on patient goals, focus of functional goals, focus on deficits, document cognitive deficits, highlight need for assistance, need for supervision, need for external structure What goes into a note - answerwhat services were provided and when/why, what was said and what happened, how the client responded to the provided service, why the skills of an OT practioner are required instead of a family member or aide OT - answerhas overall responsibility for managing and maintaining records OTA - answerassists in record keeping, recording direct service results, legally and ethically to practice within guidelines Screening - answerdocuments referral source, reason for occupational therapy, need for occupational therapy evaluation and service, brief occupational profile Evaluation - answeranalysis of occupational performance, identification of underlying factors that support and hinder performance/participation Reevaluation report - answerdocuments the results of the reevaluation process Intervention - answerdocuments contacts between the client and the occupational therapy practitioner Progress report/notes - answersummarizes intervention process and documents the clients progress toward achievement of goals