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

Logging out after each session and maintaining unique passwords are essential EHR security practices that protect patient confidentiality.

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

Under the OT Practice Framework and state laws, the supervising OT is responsible for the evaluation and its interpretation; OTAs may contribute data collection.

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 OTA must document that the supervising OT has completed the evaluation and established the plan of care before the OTA begins treatment.

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

A measurable goal specifies the task, the condition, the level of independence, and a time frame — 'don shirt independently with adaptive equipment within 2 weeks' meets all criteria.

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

Changes in patient performance levels are clinically significant and must be documented in treatment notes to justify continued skilled care.

Occupational Therapy Assistant Test Practice Test

Occupational Therapy Assistant Test Practice Test

OTA Documentation 4