OTA Documentation 2

Question 1

Which documentation format uses a structured note divided into Subjective, Objective, Assessment, and Plan sections?

Accepted Answer

SOAP note

Answer

DAP note

Answer

BIRP note

Answer

PIE note

Question 2

An OTA documents that a patient 'ambulated 50 feet with minimal assist.' This is an example of what type of documentation?

Accepted Answer

Objective data

Answer

Subjective data

Answer

Assessment data

Answer

Goal data

Question 3

Which abbreviation is commonly used in OT documentation to indicate a patient requires no physical assistance?

Accepted Answer

Ind

Answer

Min A

Answer

Mod A

Answer

CGA

Question 4

When documenting a home program provided to a patient, the OTA should record:

Accepted Answer

The program instructions and patient/caregiver comprehension

Answer

Only the date the program was given

Answer

That the OT supervised the home program delivery

Answer

The cost of the home program materials

Question 5

A patient states she is 'too tired to do therapy today.' How should the OTA document this?

Accepted Answer

As subjective data, quoting the patient directly

Answer

As objective data in the assessment section

Answer

As a plan modification only

Answer

As a contraindication requiring physician contact

Question 6

Which of the following is the most appropriate way to correct a handwritten documentation error?

Accepted Answer

Cross out with a single line, initial, and date

Answer

Use correction fluid to cover the mistake

Answer

Erase the entry and rewrite it

Answer

Write 'void' over the entire entry and start a new page

Question 7

Which component is LEAST appropriate to include in daily treatment notes?

Accepted Answer

Patient's insurance billing codes

Answer

Patient response to intervention

Answer

Progress toward goals

Answer

Any safety concerns observed