AOTA Clinical Documentation & Records 3 — Questions and Answers
Question 1: In sensory integration documentation, a 'contact note' differs from a full progress note primarily in that it:
- Is only written by OTAs
- Briefly records a communication or non-treatment contact without full SOAP structure (Correct answer)
- Replaces the need for an evaluation
- Must be co-signed by a physician
Correct answer: Briefly records a communication or non-treatment contact without full SOAP structure
A contact note documents a brief interaction such as a phone call or consultation and does not require the structured detail of a full progress note.
Question 2: When an OTA administers a sensory processing intervention under OT supervision, the supervising OT's documentation responsibility includes:
- Rewriting the OTA's notes in their own words
- Reviewing, co-signing if required by facility policy, and ensuring accuracy of the OTA's documentation (Correct answer)
- Completing all documentation on behalf of the OTA
- No responsibility if the OTA is independently licensed
Correct answer: Reviewing, co-signing if required by facility policy, and ensuring accuracy of the OTA's documentation
The supervising OT is responsible for overseeing and, where required, co-signing documentation to ensure it meets professional and facility standards.
Question 3: A therapist documents that a child displayed 'gravitational insecurity' during treatment. To be clinically defensible, this entry should also include:
- The child's diagnosis code only
- Observable behavioral indicators such as avoidance of feet leaving ground and emotional distress with height changes (Correct answer)
- A note that the parents were informed
- The theoretical explanation of the vestibular-proprioceptive mismatch
Correct answer: Observable behavioral indicators such as avoidance of feet leaving ground and emotional distress with height changes
Clinical terms like 'gravitational insecurity' must be supported by specific, observable behavioral descriptions to be defensible in the record.
Question 4: A discharge summary for an SI client should include which of the following?
- Only the final session's activities
- Summary of progress toward goals, reason for discharge, and home program recommendations (Correct answer)
- The therapist's personal opinion of the client's effort
- A request for additional funding
Correct answer: Summary of progress toward goals, reason for discharge, and home program recommendations
Discharge summaries must document the client's overall progress, rationale for ending services, and plans to support continued function.
Question 5: In the OTPF-4 framework, documentation of 'client factors' relevant to sensory integration would include:
- The clinic's scheduling policies
- Sensory functions, mental functions, and neuromusculoskeletal body functions affecting performance (Correct answer)
- The therapist's treatment philosophy
- The school's curriculum goals
Correct answer: Sensory functions, mental functions, and neuromusculoskeletal body functions affecting performance
Client factors in OTPF-4 encompass body functions and structures, including sensory and neuromusculoskeletal functions, that influence occupational performance.
Question 6: When a therapist uses a non-standardized clinical observation during an SI evaluation, documentation should:
- Omit it since it lacks psychometric support
- Describe the specific task, conditions, and client behaviors observed with clinical interpretation (Correct answer)
- Simply state 'clinical observation completed'
- Replace it with a standardized measure score
Correct answer: Describe the specific task, conditions, and client behaviors observed with clinical interpretation
Non-standardized observations gain credibility in documentation through detailed behavioral description and transparent clinical interpretation.
Question 7: Which retention period for pediatric therapy records is MOST commonly required in the United States?
- 1 year after the last date of service
- Until the minor reaches age of majority plus the state's standard adult retention period (often 7–10 years) (Correct answer)
- Indefinitely, with no expiration
- 3 years from the evaluation date only
Correct answer: Until the minor reaches age of majority plus the state's standard adult retention period (often 7–10 years)
For minor clients, records are typically retained until they reach the age of majority plus the applicable state adult retention requirement to protect future access.
AOTA Clinical Documentation & Records 3
In sensory integration documentation, a 'contact note' differs from a full progress note primarily in that it: