OTA Documentation 4

Question 1

In electronic health records (EHR), which practice best protects patient confidentiality?

Accepted Answer

Logging out after each session and using unique passwords

Answer

Sharing login credentials with trusted colleagues for efficiency

Answer

Accessing records from a public Wi-Fi network with caution

Answer

Printing records for personal reference and shredding when done

Question 2

Which statement BEST describes the role of the OTA in the initial evaluation documentation?

Accepted Answer

The OTA may contribute data but the OT is responsible for interpretation and the evaluation document

Answer

The OTA independently completes and signs the initial evaluation

Answer

The OTA must complete the evaluation within 24 hours of the patient's admission

Answer

The OTA and OT alternate responsibility for initial evaluations

Question 3

A physician's order reads 'OT evaluate and treat.' The OTA begins treatment. What should the OTA document first?

Accepted Answer

A statement confirming OT supervision and the OT's evaluation findings

Answer

The billing code for the first session

Answer

An independent assessment of the patient's deficits

Answer

The patient's prior level of function from family interview

Question 4

Which of the following is the best example of a measurable, functional short-term goal?

Accepted Answer

Patient will don shirt independently with adaptive equipment within 2 weeks

Answer

Patient will improve upper extremity strength

Answer

Patient will demonstrate improved motivation for self-care

Answer

Patient will feel more confident in daily activities

Question 5

When the OTA upgrades a patient's assist level from 'moderate assist' to 'minimal assist,' this change should be:

Accepted Answer

Documented in the treatment note as evidence of progress

Answer

Reported verbally to the supervisor only

Answer

Held until the next formal reassessment period

Answer

Noted in the patient's personal journal, not the medical record

Question 6

An OTA documents an intervention that was not actually performed. This action constitutes:

Accepted Answer

Healthcare fraud

Answer

A minor charting omission

Answer

An acceptable practice if the intervention was planned

Answer

A documentation shortcut permitted during high-census periods

Question 7

Which term describes the set of standards that specify what information must be included in OT documentation for Medicare reimbursement?

Accepted Answer

Medicare Coverage Policies and Local Coverage Determinations (LCDs)

Answer

ICD-10 coding requirements

Answer

ADA documentation standards

Answer

OSHA charting requirements