NBCOT Documentation and Service Management

Question 1

Which documentation format organizes notes by Subjective, Objective, Assessment, and Plan?

Accepted Answer

SOAP

Answer

DAP

Answer

SIRP

Answer

BIRP

Question 2

A goal that is Specific, Measurable, Attainable, Relevant, and Time-bound is called a:

Accepted Answer

SMART goal

Answer

Functional goal

Answer

Long-term goal

Answer

Occupational goal

Question 3

Which documentation must be completed before OT services begin under Medicare regulations?

Accepted Answer

Initial evaluation and plan of care

Answer

Discharge summary

Answer

Quarterly progress note

Answer

Annual reassessment

Question 4

A therapist documents that a client requires 'minimum assistance' for dressing. This means the client provides approximately:

Accepted Answer

75% or more of the effort

Answer

0–25% of the effort

Answer

25–49% of the effort

Answer

50–74% of the effort

Question 5

What is the primary purpose of a discharge summary in OT documentation?

Accepted Answer

To summarize outcomes, progress toward goals, and recommendations for follow-up

Answer

To justify continued services

Answer

To bill for the final session only

Answer

To transfer the client to another OT

Question 6

Under the Medicare Cap exception process, an OT can document that therapy services are medically necessary beyond the cap using:

Accepted Answer

The KX modifier in billing with supporting documentation of medical necessity

Answer

A physician order alone

Answer

A COPM score

Answer

Verbal authorization from the supervisor