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OCTH 746 quiz 1
| Question | Answer |
|---|---|
| client-centered, occupation-centered, evidence-based, and culturally relevant | principles that guide practice |
| evaluation: occupational profile, analysis of occupational performance, synthesis of evaluation; intervention: plan, implement, review; outcomes: select outcome measures, measure progress, adjust goals and interventions | components of OT process |
| purposes: health record (client care management), reimbursement, discharge planning, utilization review, legal protection, quality improvement, health system accreditation, education/research, client access | documentation |
| show the need for skilled OT; skilled = actively participating in tx. of pt. | documentation |
| with a ____ you need to document a brief contact note to document that you have seen it and completed your initial eval | referral |
| type of documentation: referral info, recommendation/determination | screen |
| type of documentation: referral source and info, occupational profile, reason for referral, assessments and results, interpretation of info gathered, recommendations, goals, plan/frequency of intervention, billing codes | initial eval |
| type of documentation: SOAP format | daily note |
| type of documentation: goals addressed, summary of progress, changes/modifications, current level of function, plan and recommendation | progress note |
| type of documentation: same info at eval, progress on goals, changes to goals, results of findings on re-admin of assessments, recommendations, plan, length of re-certification period | re - evaluation |
| type of documentation: summary of progress, summary of interventions provided, referrals/recommendations, DME/AE needs, plan for continued OT, caregiver instructions | discharge summary |
| client has not been referred, another professional recommends OT, not reimbursable, Medicare part B | screen |
| includes current level of function compared to prior level which is used to measure therapy outcome, rehab potential, domain of concern, occupational history/occupational profile | initial eval |
| along with initial eval must include a daily note to justify additional charges | initial eval treatment note |
| when making these consider diagnosis, context, underlying impairments, motivation, setting, others; tie to occupation | goals |
| format: level of assistance + occupation + contributing factors OR contributing factor + area of occupation affected | functional problem statement |
| type of goal: Client, Occupation, Assist level, Specific conditions, Timeline | COAST goals |
| indep. = (I), set-up and supervision = NA, stand-by assistance = SBA, contact guard assistance CGA, minimal assistance Min A, moderate assistance = Mod A, maximal assistance = Max A, dependent = dep | levels of assistance |
| duration: acute care = state "by discharge", include LTGs only; sub-acute = STG is 2 weeks, LTG is by discharge | duration of goals |
| part of SOAP note: client's report, use "", briefest part, on initial eval includes occupational profile, should relate to session, ex. pain rating | subjective |
| part of SOAP note: facts, measurable, quantifiable, observable, start with purpose of session, indicate barriers to participation and how intervention addressed those, concise and specific | objective |
| part of SOAP note: your clinical opinion, problems, progress, rehab potential and rationale, must relate to "O", analyze and interpret, build case for continued OT | assessment |
| part of SOAP note: what will you do next, referrals, for initial eval goals go here, include frequency/intensity/duration | plan |
| provides justification for medical necessity of tx., must be written by OT, done at least every 10th visit, typically weekly | progress note |
| must determine certification period in initial eval, weekly/biweekly progress notes, 30 day re-eval for Medicare part B, typical time to re-eval/update goals if needed | re - certification |
| type of CPT code time: prepping to see ct., reviewing chart, communicating with other professionals; no minutes counted | pre - service time |
| type of CPT code time: direct ct. therapy tx.; face-to-face minutes counted to determine CPT units billed | intra - service time |
| type of CPT code time: documentation of session in EMR, arranging for tx., follow-up comm. with ct. or family or other professionals; no minutes counted | post - service time |
| medical equipment: collects urine; OT should keep it below the bladder, make sure it does not get hooked or kinked, dressing with it, be cautious of how full it is | foley catheter |
| medical equipment: collects stool; OT should be cautious of positioning | ostomy collection pouch |
| medical equipment: drains wounds; OT should be cautious of positioning, dressing with it on, keep it with patient while moving | wound vac |
| medical equipment: feeding/medications; OT should keep it clipped to patient to prevent tugging or pulling | nasogastric tube |
| medical equipment: suction and collection of fluids, prevents tissue damage; OT can use to clear excess fluids in the back of the throat | vacuum regulator and collection device |
| medical equipment: provide supplemental oxygen, shows how much O2 pt. is receiving; OT should be aware of oxygen levels while working with pt. | nasal cannula and O2 flow meter |
| medical equipment: provides fluids, medication, and nutrients; OT should be cautious of positioning as well as line when moving around, dressing | IV pump / line |
| medical equipment: promotes circulation in LEs; OT should do pt. ed. and promote occupational engagement | LE sequential compression pumps / vasopneumatic pumps |
| medical equipment: measures oxygen saturation in blood; OT should be aware of pt.'s blood oxygen saturation when ambulating, can be removed if pt. is stable | pulse oximetry / oxygen saturation monitor |
| medical equipment: measures blood pressure; OT may be asked to take pt. BP or may need to check BP if pt. reports not feeling well or if they appear unwell | blood pressure cuff |
| medical equipment: monitors pt.'s heart rhythm; OT should be aware of placement and positioning | telemetry / EKG wires |
| medical equipment: drains excess fluid and air and provides suction; OT should keep below chest for proper drainage, be aware of tubing, dressing | chest tube |
| medical equipment: provides mechanical breathing; OT needs to move it with pt. and be mindful of positioning and placement | ventilator |
| medical equipment: provides a direct airway to trachea | tracheostomy tube |
| medical equipment: clears secretions from airway | suction catheter |
| medical equipment: inserted directly into stomach to provide nutrition; OT should be mindful of where they are when doing ADLs, could impact dressing when first placed | gastric tube |
| medical equipment: manages pressure in brain and spinal cord by removing excess CSF; OT needs to maintain drain at precise height | cerebrospinal fluid drain |
| precautions: no crossing legs/ankles, avoid bending beyond 90 degrees, extend affected leg when standing, no twisting | total hip arthroplasty |
| precautions: no kneeling, twisting, or pivoting; no pillows under knees; no crossing legs/ankles; point toes straight ahead | total knee arthroplasty |
| precautions: avoid bending forward/backwards at waist, do not twist, no lifting, logroll to get out of bed, go for short frequent walks, use pillows between legs or under knees, avoid reaching; BLT | back / spine |
| precautions: no AROM of shoulder, use arm sling, no lifting, no shoulder movements behind back, no excessive stretching or sudden movements, no supporting body weight on hands, keep incision clean and dry | rotator cuff repair |
| precautions: strict immobilization in sling, no active or resisted movement of arm, sleep with arm elevated, no lifting | proximal humerus fracture |
| precautions: no lifting, no pushing or pulling, do not raise arm over 90 degrees on pacemaker side, careful around magnets | pacemaker placement |
| precautions: no pushing, pulling, or lifting; avoid raising arms above head or behind back, no holding breath, keep arm close to body, logroll to get out of bed, keep sternum in neutral position to avoid strain | sternal precautions |
| precautions: maintain neutral spine, stabilize spine, avoid bending and twisting of neck, no lifting, no high-impact or strenuous activities | cervical spine injury |
| process: chart review, safety and precautions, prepare area, assess patient status (physical, cognitive, other), intervention, education, communication | OT delivery |
| eval: interview/occupational profile, quick screens, functional assessment, select in-depth evaluation, occupational performance | top - down |
| ADL assessment tool: 18 items - 13 motor and 5 cognitive; 6 categories - self care, sphincter control, mobility, locomotion, communication, social cognition | functional independence measure (FIM) |
| ADL assessment tool: required in PAC; measures self care and mobility | Section GG (Continuity Assessment Record and Evaluation) |
| assessment tool levels of function: patient completes activity by him/herself with no assistance from a helper | independent |
| assessment tool levels of function: helper sets up or cleans up, patient completes activity, helper assists only prior to or following activity | set up or clean up assistance |
| assessment tool levels of function: helper provides verbal cues or touching/steadying assistance as patient completes activity, assistance may be provided throughout activity or intermittently | supervision or touching assistance |
| assessment tool levels of function: helper does less than 1/2 of effort; helper lifts, holds, or supports trunk or limbs but provides less than 1/2 of effort | partial / moderate assistance |
| assessment tool levels of function: helper does more than 1/2 of effort, helper lifts or holds trunk or limbs and provides more than 1/2 of effort | substantial / maximal assistance |
| assessment tool levels of function: helper does all of the effort, patient does none of effort to complete task | dependent |
| ADL assessment tool: 3 scores-task independence, task safety, task adequacy | Performance Assessment of Self - Care Skills |
| IADL assessment tool: standardized, occupation-based, client-centered eval; requires certification; includes over 130 tasks; steps-interview ct., observation of performance, assessment of quality of task performance; motor and process skills | Assessment of Motor and Process Skills (AMPS) |
| IADL assessment tool: scoring-4 = competent performance, 3 = questionable performance, 2 = ineffective performance, 1 = unacceptable performance | AMPS |
| normal range: 50 to 100 | heart rate |
| normal range: 120/80 | blood pressure |
| normal range: 90-100% | O2 |
| normal range: 12-20 per minute | respiration |
| normal range: men - 13.5 to 17.5, women - 12 to 15 | hemoglobin |
Created by:
emma.scarmon-coyotes
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