OTA Documentation 3

Question 1

Under HIPAA, which of the following is an example of Protected Health Information (PHI)?

Accepted Answer

A patient's name combined with their diagnosis and treatment dates

Answer

A patient's therapy diagnosis without any identifying information

Answer

Aggregate therapy outcome statistics with no names

Answer

General facility policies posted in the waiting room

Question 2

An OTA wants to send a patient's evaluation summary to the referring physician. What must occur first?

Accepted Answer

A signed patient authorization or a HIPAA-permitted disclosure must be in place

Answer

The OT supervisor must co-sign the summary

Answer

The facility billing department must approve the release

Answer

The patient's family must be notified

Question 3

Which of the following best describes a functional outcome measure in OT documentation?

Accepted Answer

The patient's ability to perform meaningful daily activities

Answer

A score on a muscle strength test

Answer

The number of therapy sessions attended

Answer

The therapist's subjective impression of improvement

Question 4

How long are medical records typically required to be retained for adult patients under most state laws?

Accepted Answer

7–10 years

Answer

1 year

Answer

3 years

Answer

Indefinitely

Question 5

An OTA documents that a patient achieved a goal before the target date. This information is most important for:

Accepted Answer

Reassessing and updating goals to reflect continued progress

Answer

Discontinuing therapy immediately

Answer

Requesting an extension of the therapy authorization

Answer

Filing a discharge summary without further assessment

Question 6

Which of the following must be included in a discharge summary?

Accepted Answer

Patient's status at discharge, goals met, and recommendations for follow-up

Answer

A list of all staff who treated the patient

Answer

The patient's full insurance coverage details

Answer

A comparison of the facility's outcomes to national benchmarks

Question 7

Which of the following is the primary purpose of documenting skilled services in OT?

Accepted Answer

To justify reimbursement and demonstrate medical necessity

Answer

To track the therapist's productivity metrics

Answer

To satisfy state licensure renewal requirements

Answer

To provide data for facility marketing materials