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

PHI includes any individually identifiable health information, such as a patient's name paired with diagnosis or treatment details.

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

Releasing health information requires either a signed patient authorization or a HIPAA-permitted purpose such as treatment coordination.

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

Functional outcome measures assess how well a patient can perform meaningful occupational activities such as dressing, cooking, or work tasks.

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

Most states require adult medical records to be retained for a minimum of 7–10 years, though specific requirements vary by state.

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

When a goal is met early, the OTA should collaborate with the supervising OT to reassess and establish new, more challenging goals.

Occupational Therapy Assistant Test Practice Test