OTA Documentation 5

Question 1

A patient refuses to participate in a scheduled OT session. How should the OTA document this?

Accepted Answer

Document the refusal, the reason stated by the patient, and any education provided

Answer

Leave the session time blank to avoid drawing attention

Answer

Document that the session occurred without specifying outcomes

Answer

Only document if the refusal happens more than three times

Question 2

Which documentation system records only significant changes or exceptions from a standard baseline?

Accepted Answer

Exception-based charting (charting by exception)

Answer

SOAP notes

Answer

Narrative notes

Answer

PIE notes

Question 3

When an OTA observes that a patient's condition has significantly declined, the most appropriate first action is to:

Accepted Answer

Notify the supervising OT immediately and document the change

Answer

Update the goal in the medical record independently

Answer

Continue with the current plan of care until the next scheduled reassessment

Answer

Contact the patient's family before informing the OT

Question 4

The term 'co-signature' in OTA documentation means:

Accepted Answer

The supervising OT signs the OTA's note to indicate review and acceptance

Answer

The OTA signs twice on the same note for verification

Answer

Both the patient and the OTA sign the treatment note

Answer

A second OTA cosigns to verify accuracy

Question 5

Which of the following is NOT typically included in a daily OT treatment note?

Accepted Answer

The patient's long-term prognosis

Answer

Response to the intervention

Answer

Skilled interventions performed

Answer

Patient's progress toward goals

Question 6

A patient is seen in a skilled nursing facility. Which payer-specific documentation requirement is most important for the OTA to understand?

Accepted Answer

Medicare's Resident Assessment Instrument (RAI) and MDS process

Answer

ADA accessibility audit requirements

Answer

Private pay billing schedules

Answer

OSHA safety documentation logs

Question 7

When writing an OT progress note, which of the following best demonstrates skilled care?

Accepted Answer

'Patient required skilled cuing strategies and graded task modification to safely sequence and complete bathing with minimal assist.'

Answer

'Patient performed ADLs as before.'

Answer

'Patient is progressing well and seems motivated.'

Answer

'Patient completed tasks; no issues noted.'