NBCOT Documentation and Service Management 4

Question 1

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?

Accepted Answer

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

Answer

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

Question 2

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

Accepted Answer

Uses subjective, judgmental language rather than objective behavioral observations

Answer

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

Question 3

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

Accepted Answer

Plan of care (POC)

Answer

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

Question 4

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?

Accepted Answer

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

Answer

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

Question 5

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

Accepted Answer

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

Answer

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.

NBCOT - National Board for Certification in Occupational Therapy Practice Test

NBCOT - National Board for Certification in Occupational Therapy Practice Test

NBCOT Documentation and Service Management 4