p.2
Purposes of Occupational Therapy Documentation
What type of record does documentation create regarding client status?
A chronological record of client status, services provided, performance, response to intervention, and outcomes.
p.18
Planning and Goal Setting in S.O.A.P
What is another method to sustain standing position?
Leaning on a wall to transfer bean bags sideways, then upgrading to higher levels that require weight shifting.
p.18
Planning and Goal Setting in S.O.A.P
What is one objective that can be achieved using therapeutic activities?
To sustain standing position for a specified duration by leaning on a firm desk to transfer and place bean bags.
p.8
Subjective and Objective Information in S.O.A.P
What type of information is included in the subjective section of S.O.A.P?
Anything the client says relevant to the therapy, including statements from family, care workers, or other healthcare professionals.
p.4
Confidentiality in Occupational Therapy Documentation
What measures should OT students take to protect records?
Keep records safe from theft, loss, false access, or damage.
p.19
Assessment and Analysis in S.O.A.P
What types of support levels are evaluated during tasks?
Free-standing, support with rail, or hands supported on the desk.
p.9
S.O.A.P Approach for Documentation
What type of information is included in the 'Objective' section?
Clinical measurements or outcomes and observations about the patient’s/client’s actions or behaviors.
p.19
Assessment and Analysis in S.O.A.P
What is one way to measure balance during treatment?
Time to endure a balanced standing position or to sustain an identified standing position.
p.12
Subjective and Objective Information in S.O.A.P
What is the purpose of the 'Subjective' section in the S.O.A.P. approach?
To capture the patient's personal experiences and feelings regarding their condition.
p.9
S.O.A.P Approach for Documentation
What is another example of objective information?
Patient was able to walk without assistance for 3m along the hallway from bedroom to bathroom.
p.16
Assessment and Analysis in S.O.A.P
What limitation does the individual have due to spasticity and inadequate motor control?
Cannot sustain a free standing position and shift weight to reach upward and forward.
p.11
Planning and Goal Setting in S.O.A.P
What should be indicated in the plan regarding the therapy?
The need for change or adaptation.
p.13
Importance of Documentation in Occupational Therapy
What do terms like Fair, Poor, and Satisfactory need in documentation?
Clear definitions and context.
p.11
Planning and Goal Setting in S.O.A.P
What should be specified in the plan regarding therapy outcomes?
New goals and objectives.
p.4
Standards for Good Record Keeping
What must OT students follow during clinical placements regarding report writing?
Clear procedures set by each clinical setting or service provider.
p.8
Subjective and Objective Information in S.O.A.P
Give an example of subjective information from a client.
"I don’t want to use this wheelchair. I don’t like it."
p.17
Planning and Goal Setting in S.O.A.P
What is one objective for sustaining standing position?
To sustain standing position for ___ min. by leaning on a firm desk to pick up materials.
p.17
Planning and Goal Setting in S.O.A.P
What is an objective involving support from a desk?
To support left hand on the desk to sustain standing position for ____ min. while reaching/placing materials.
p.5
Standards for Good Record Keeping
What should be avoided in documentation?
Jargons, unexplained acronyms, abbreviations, or terminology.
p.2
Purposes of Occupational Therapy Documentation
What is one purpose of documentation in occupational therapy?
To communicate true and accurate information about the client from the occupational therapy perspective.
p.1
Documentation of Occupational Performance
How should documentation describe the services provided?
It should describe the depth and breadth of services to meet the complexity of individual client needs.
p.14
Importance of Documentation in Occupational Therapy
What safety issues might arise from the individual's walking problems?
Issues when walking to the toilet, navigating crowded situations, getting on and off the bus, and reaching for materials on overhead cupboards.
p.13
Importance of Documentation in Occupational Therapy
What is an example of a vague statement in documentation?
Fair standing tolerance or walking balance without specifying duration or assistance needed.
p.6
Confidentiality in Occupational Therapy Documentation
What must be complied with to maintain confidentiality of data?
The Privacy Ordinance and institutional policies.
p.10
Assessment and Analysis in S.O.A.P
What improvement was noted in the client's typing skills?
Client showed improvement in typing speed and accuracy after 10 training sessions, with speed increasing by 30% but accuracy dropping by 80% compared to baseline.
p.5
Standards for Good Record Keeping
How should corrections be made in records?
Corrections must be made clearly to show the original entry.
p.15
Assessment and Analysis in S.O.A.P
How can the range of motion (ROM) of the upper limbs be assessed?
Using a goniometer or testing functional range of movement.
p.19
Assessment and Analysis in S.O.A.P
What can be measured to assess treatment outcomes pre- and post-intervention?
Time to complete the task with identified physical demand.
p.1
Importance of Documentation in Occupational Therapy
Why is documentation necessary in occupational therapy?
It is necessary whenever professional services are provided to a client.
p.18
Planning and Goal Setting in S.O.A.P
How can one support their standing position using their hands?
By supporting the left hand on the desk while reaching or placing bean bags with the other hand.
p.17
Planning and Goal Setting in S.O.A.P
What is an example of a specific treatment goal?
To improve standing tolerance to reach and place materials in the overhead cupboard.
p.9
S.O.A.P Approach for Documentation
Give an example of objective information.
Patient engaged in a 10-minute conversation about return to home after operation and responded to questions about fears on return.
p.5
Standards for Good Record Keeping
What must be obtained before recording patient/client information?
Patient/client’s consent.
p.16
Assessment and Analysis in S.O.A.P
How long can the individual stand with support?
5 minutes with one hand supported on the desk.
p.6
Confidentiality in Occupational Therapy Documentation
What should be avoided regarding confidential information?
Unnecessarily accessing, downloading, or making copies out of clinical units.
p.11
Planning and Goal Setting in S.O.A.P
What is important to continuously provide in the therapy plan?
Updates to the therapy plan.
p.15
Assessment and Analysis in S.O.A.P
What scale is used to assess muscle tightness and spasticity in the lower limbs?
The Modified Ashworth Scale.
p.18
Planning and Goal Setting in S.O.A.P
What is the goal of sustaining a free standing position?
To perform a table task without leaning on a wall.
p.14
Case Illustration and Specificity in Documentation
What is the age and condition of the individual in the case example?
A 40-year-old with Cerebral Palsy Diplegia.
p.3
Documentation of Occupational Performance
What types of information should be included in the documentation?
Client information, referral information, and occupational profile.
p.16
Assessment and Analysis in S.O.A.P
What should be included in the assessment of standing balance or tolerance?
Quantified/measurable performance in specific tasks or activities.
p.5
Standards for Good Record Keeping
What is a key requirement for all documents and records in good record keeping?
They must be fit for purpose.
p.10
Assessment and Analysis in S.O.A.P
What should be detailed in the Assessment/Analysis section?
Progression, regression, or no remarkable change in occupational performance.
p.18
Planning and Goal Setting in S.O.A.P
How can the standing position objective be upgraded?
By using different heights for placing bean bags, such as desk level, shoulder height, or above head.
p.4
Standards for Good Record Keeping
What do clinical settings or service providers use to ensure record quality?
Their own means of audit and quality control.
p.8
Subjective and Objective Information in S.O.A.P
What does the client mean when they say, "I can see myself making some improvements at home"?
The client reported that he has made some improvements at home.
p.4
Confidentiality in Occupational Therapy Documentation
What is a crucial aspect of handling patient information?
Maintain confidentiality.
p.3
Documentation of Occupational Performance
What are the expected outcomes of the documentation process?
Identification of necessary interventions and expected treatment outcomes.
p.9
S.O.A.P Approach for Documentation
Provide an example of a task completed by the patient that demonstrates objective information.
Patient can finish 20 packs of assemble work in 15 minutes without asking for assistance.
p.5
Standards for Good Record Keeping
What is important about the organization of records?
They should be organized and structured in a systematic way.
p.5
Standards for Good Record Keeping
What must all records include regarding their creation?
They must be signed, dated, and timed.
p.11
Planning and Goal Setting in S.O.A.P
What should be indicated in the plan regarding additional services?
Referrals to other services.
p.15
Assessment and Analysis in S.O.A.P
What clinical observations are important for assessing standing balance?
Observing any associated reactions, extensor tone, spasms, or uncontrolled movements in the lower limbs.
p.2
Purposes of Occupational Therapy Documentation
How does documentation articulate the rationale for occupational therapy services?
It reflects the relationship of those services to client outcomes, showcasing the practitioner's clinical reasoning and professional judgment.
p.1
Purposes of Occupational Therapy Documentation
What should documentation reflect in occupational therapy?
The nature of services provided and the clinical reasoning of the occupational therapy practitioner.
p.3
Documentation of Occupational Performance
What is the purpose of documentation in occupational performance?
To gather information and data for analysis of occupational performance and identification of problems.
p.14
Assessment and Analysis in S.O.A.P
What factors affect the individual's walking performance?
Walking balance, stability, gait pattern, and walking endurance due to spasticity in lower limbs.
p.14
Planning and Goal Setting in S.O.A.P
What specific task is being assessed in the case example?
Sustain standing position to reach and pick materials from overhead cupboards.
p.14
Assessment and Analysis in S.O.A.P
What aspect of the individual's performance is being evaluated?
Whether his standing balance/tolerance affects his performance in the specific task.
p.11
Planning and Goal Setting in S.O.A.P
What should the plan be based on in the S.O.A.P approach?
It should be based on S.O.A (Subjective and Objective information).
p.11
Planning and Goal Setting in S.O.A.P
What should be planned for future evaluations?
The time for re-evaluation.
p.15
Planning and Goal Setting in S.O.A.P
Why is the time factor important in assessing standing balance?
It helps determine how long the individual can sustain free or supported standing, serving as a baseline for goal setting.
p.19
Assessment and Analysis in S.O.A.P
What height level is assessed in treatment outcomes?
The height level the individual can reach for items while maintaining balance and stability.
p.3
Documentation of Occupational Performance
What types of assessments are used in the documentation process?
Interviews, record reviews, observations, standardized and/or non-standardized assessments.
p.10
Assessment and Analysis in S.O.A.P
What is the basis for the Assessment/Analysis in the S.O.A.P approach?
It is based on the information given in Subjective (S) and Objective (O).
p.11
Planning and Goal Setting in S.O.A.P
What aspects of the intervention should be specified in the plan?
The intended frequency and duration.
p.19
Assessment and Analysis in S.O.A.P
How can frequency of balance loss be quantified?
By counting the number of times the individual falls back into a chair or drops items.
p.1
Standards for Good Record Keeping
What type of information should documentation provide?
Factual and appropriate information to ensure safe and effective service delivery.
p.19
Assessment and Analysis in S.O.A.P
How is the overall treatment outcome summarized?
Based on a summary of the above indicators.
p.12
Subjective and Objective Information in S.O.A.P
What type of information is included in the 'Objective' section of S.O.A.P.?
Measurable and observable data, such as test results and physical examinations.
p.12
Assessment and Analysis in S.O.A.P
What is the focus of the 'Assessment' section in the S.O.A.P. format?
To analyze the subjective and objective information to determine the patient's progress and needs.
p.13
Importance of Documentation in Occupational Therapy
What should be specified when stating 'Improve muscle strength/ROM'?
The extent of improvement.
p.13
Importance of Documentation in Occupational Therapy
What does 'Poor hand function' need to clarify?
The degree of impairment.
p.13
Documentation of Occupational Performance
How should performance components relate to occupational performance?
They should be connected to specific tasks, activities, or occupations.
p.15
Assessment and Analysis in S.O.A.P
What should be observed in the upper limbs that may affect trunk alignment?
Flexor tone or spasticity that can upset trunk alignment and balance.
p.4
Confidentiality in Occupational Therapy Documentation
What should OT students avoid doing with patients' files?
Never leave them unattended.
p.3
Documentation of Occupational Performance
What does the analysis of occupational performance include?
Description and judgment about performance components, skills, patterns, contexts, activity demands, and client factors.
p.17
Planning and Goal Setting in S.O.A.P
What is another objective for sustaining standing position without support?
To sustain free standing position for ____ min. to pick up materials from the cupboard without leaning on the desk.
p.17
Planning and Goal Setting in S.O.A.P
How can a walking frame be used in treatment goals?
To sustain standing position for ___ min. by holding onto a walking frame with the left hand while reaching/placing materials.
p.5
Standards for Good Record Keeping
How should patient/client information be recorded?
It should be clear and legible.
p.11
Planning and Goal Setting in S.O.A.P
What should be noted in the plan regarding intervention?
The intended intervention techniques.
p.6
Confidentiality in Occupational Therapy Documentation
How should electronic storage devices and documents containing confidential information be secured?
In a safe place or password encrypted.
p.15
Assessment and Analysis in S.O.A.P
What is the first step in analyzing standing balance and tolerance?
Identify the components needed for standing balance and tolerance.
p.12
S.O.A.P Approach for Documentation
What does S.O.A.P. stand for in the context of documentation?
Subjective, Objective, Assessment, and Plan.
p.9
S.O.A.P Approach for Documentation
How should observations in the 'Objective' section be stated?
In behavioral terms without interpretation.
p.3
Documentation of Occupational Performance
What is included in the summary and analysis section of the documentation?
Interpretation and summary of data related to occupational profile and identified deficits.
p.12
Planning and Goal Setting in S.O.A.P
What does the 'Plan' section in S.O.A.P. entail?
It outlines the proposed interventions and goals for the patient's treatment.
p.10
Assessment and Analysis in S.O.A.P
What does the Assessment/Analysis indicate in the S.O.A.P approach?
It indicates professional justification with clinical reasoning according to the interpretation of assessment results and the patient’s response.
p.16
Assessment and Analysis in S.O.A.P
What can the individual do while standing with support?
Reach and place work materials from the overhead cupboard onto the desk.
p.5
Standards for Good Record Keeping
How should records be arranged?
They should be chronological.
p.15
Assessment and Analysis in S.O.A.P
What does supported standing refer to?
The ability to stand with support, assessing the individual's capacity.
p.16
Assessment and Analysis in S.O.A.P
What is a vague statement regarding standing endurance?
'He has poor/inadequate standing endurance.'
p.16
Assessment and Analysis in S.O.A.P
What specific information should be included instead of vague statements?
Details about time, action, and environmental demand in performing a task.
p.12
Purposes of Occupational Therapy Documentation
How does the S.O.A.P. approach benefit occupational therapy documentation?
It provides a structured and clear method for documenting patient information and treatment plans.
p.10
Assessment and Analysis in S.O.A.P
Give an example of a positive assessment in social interaction abilities.
Patient demonstrated an improvement in social interaction abilities and can now interact with peers for sustained periods, such as in a 30-minute newspaper discussion group.
p.6
Confidentiality in Occupational Therapy Documentation
What should be done with confidential information when it is no longer needed?
It should be deleted or destroyed.
p.15
Assessment and Analysis in S.O.A.P
How can muscle strength of the lower limbs be assessed?
Using Manual Muscle Testing (MMT) to evaluate quadriceps and hamstrings strength.
p.13
Standards for Good Record Keeping
What is a key point to note in documentation and report writing?
Be specific and detailed in descriptions.
p.15
Assessment and Analysis in S.O.A.P
What ability is assessed through simulated tasks in standing balance?
The ability to maintain standing balance or weight shifting while reaching for objects.
