NCTRC Exam- Documentation Practice Test.

NCTRC Exam- Documentation Practice Test. 1. Interpretation and Documentation of Assessment Results 2. source-oriented medical record (somr) 3. Individualized In- tervention Plan 4. Writing Measur- able Goals and After carefully assessing the pt, it is necessary to enter the assessment info into the medical chart/tx plan when documenting the assessment results, the CTRS summarizes the assessment info--important to include info ab the pt's strengths, weaknesses, process used to collect the assessment info, & mutually agreed upon tx goals & interventions patient information is arranged according to who supplied the data- the patient, doctor, specialist, or someone else. Describes all problems and treatments on the same form in a simple chronological order. an individualized plan of care or intervention for a person served by a qualified TR/RT professional (CTRS) based on assessed strengths and needs, and includes goals, objectives and intervention strategies aimed at fostering desirable and necessary outcomes also known as the treatment plan document kept in the client's chart CTRS must be able to write measurable goals and behavioral objectives Behavioral Objec- based on the client's strengths & weaknesses as determined by the assessment, tives 5. Bloom's Taxono- my 6. Krathwohl's Tax- onomy measurable goals & behavioral objectives are written 7 level taxonomy starting w knowledge, comprehension, application, analysis, synthesis, evaluation often used for cognitive domain 5 level taxonomy starting w receiving, responding, valuing, organization, charac- terization by value often used for the attective domain 7. behavioral objec- tives 8. progress/func- tional status 9. modification of intervention plan 10. Discharge and Transition Plan- ning indicators that a goal has been achieved objectives must have 3 components: 1. conditions that state when or where the outcome behavior should occur 2. an action verb that describes the expected behavior 3. criteria that describes how well/often the client must perform the behavior ex. measure/objective: when asked a question by the statt, client will respond politely within 30 seconds. condition: "when asked a question by statt" action verb: "will respond" criteria: "politely within 30 seconds" after completing the individualized intervention plan, CTRS will enter progress notes dependent on the requirements f the agency after working w the pt, CTRS must provide periodic updates on the pt's progress towards meeting their goals the frequency of providing updates on the pt's progress is determined by agency guidelines, accreditation standards, and regulatory agencies as clients participate in TR services, their needs & behaviors will change as they attain their goals, new goals & objectives w supporting interventions may need to be added discharge planning should begin the day the pt arrives on the unit, discharge usually occurs when goals have been achieved