Exam Preview for 5507: Skilled OT Documentation: Medical Necessity

Skilled OT Documentation: Medical Necessity in the Evaluation and Plan of Care

Please note: exam questions are subject to change.

1. What does the evaluation and plan of care (POC) do? Establishes baseline data Identifies the functional loss and need for skilled therapy Indicates projected outcome and path to facilitate outcome achievement All of the above
2. Which of the following is NOT TRUE about an evaluation? It should be individualized for the client with goals and discharge location. It should be complete and address all areas of functional performance. It does not need to be signed and dated by the MD as long as the therapist signs If treatment is provided on the day of the evaluation, a treatment note should be completed.
3. Where should you get the diagnosis code for a client under Medicare Part A? From the hospital transfer/discharge face sheet or summary provided to the facility From the client From the caregiver From the prescription note
4. When you document the reason for referral (RFR), you need to justify the need for skilled services based on the client's: Medical condition Current problems Concerns for safe function All of the above
5. Which of the following is an example of an appropriate goal? Increase R shoulder flexion and abduction to WFL for ADL Increase R shoulder flexion and abduction to 160 degrees to be able to wash hair (I) in 3 weeks Increase meal prep in the kitchen using a cane Increasing standing tolerance to 10 minutes