Documentation and Service Management Flashcards

Under HIPAA, which of the following is considered a legitimate reason for an OT to disclose a client's protected health information (PHI) without written authorization?

Answer: Reporting a communicable disease to public health authorities as required by law

HIPAA permits disclosure of PHI without authorization for mandated public health reporting activities such as communicable disease notification.

A therapist documents 'Client appears unmotivated and uncooperative.' This type of entry is problematic primarily because it:

Answer: Uses subjective, judgmental language rather than objective behavioral observations

Clinical notes must reflect objective, observable behavior rather than subjective characterizations that can reflect bias and are not measurable.

Which document outlines the specific services to be provided, frequency, duration, and measurable goals agreed upon at the start of OT services?

Answer: Plan of care (POC)

The plan of care formally establishes the scope, frequency, duration, and goals of OT services and requires physician signature in most reimbursement settings.

An OT working in a skilled nursing facility (SNF) must demonstrate 'skilled care' in documentation to justify Medicare Part A reimbursement. Which entry BEST demonstrates skilled care?

Answer: Therapist graded resistance and cueing during dynamic balance training to safely progress client toward functional ambulation on uneven surfaces

Skilled care documentation must reflect the therapist's clinical judgment, complexity of service, and why the intervention requires a licensed professional.

When a client's progress has plateaued but maintenance therapy is recommended, the OT's documentation should focus on:

Answer: Justifying the need for a skilled therapist to prevent decline and maintain current functional level

Medicare and most payers cover maintenance therapy when a skilled professional is required to safely carry out or design the maintenance program, even without new functional gains.

A client signs a release of information form requesting that records be sent to their attorney. Which action is MOST appropriate?

Answer: Fulfill the request per facility policy, sending only the records specified in the authorization

A valid signed authorization allows release of the specific records identified; the therapist should follow facility policy and honor the scope of the signed authorization.

Which functional outcome measure is MOST commonly used to document occupational performance in activities of daily living for inpatient rehabilitation settings and directly aligns with reimbursement documentation?

Answer: Functional Independence Measure (FIM)

The FIM is the standard ADL outcome measure embedded in the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) used for Medicare reimbursement.