Exam Preview for 1178: Documentation Essentials February 15, 2012

Documentation Essentials

Please note: exam questions are subject to change.

1. On a resident evaluation, pick the prior level of function statement below that will best support the skilled services required for the plan of care: Resident lived in apartment with wife. Resident lives in independent living apartment with wife. Was independent in all self-cares and IADLs including driving and lawn work. Did not require any assistive mobility or ADL devices. Resident was independent in self cares. Resident is independent.
2. Which of the following statements is strongest for documenting reason for referral on the therapy evaluation? Patient was discharged from the hospital with therapy orders. Resident has had a functional decline in status requiring therapy services. Resident was admitted with orders. Patient has had a functional decline in bed mobility, functional transfers and strength following a hospitalization with a CVA.
3. Pick the best skilled statement for a therapy progress note to justify the therapy services provided. Resident was seen 3/5 times this week. Skilled OT services provided including ADL retraining, UE strengthening, dynamic standing balance and group treatment. Provided weight shifting activities including UE movements in PNF patterns outside of the base of support in order to improve dynamic standing balance. UE exercises provided under therapist supervision with constant modification based on O2 sats and HR. All of the above are adequate statements
4. Which of the following is an incorrect statement for medicare coverage guidelines: Therapy services do not need to be considered under the accepted standards of medical practice; interventions can be experimental as long as the treatment is effective. Therapy services must be of a level of complexity and sophistication or the condition of the patient must be of the nature that requires the judgement and skills of a therapist. There must be the expectation of the patient’s condition will improve in a reasonable period of time. Therapy services must be reasonable and necessary for the treatment of the patient’s condition including the frequency and duration of the therapy services provided.
5. Which of the following is most accurate statement about documentation in a discharge note. The discharge note should have the goals from the evaluation listed and the resident’s final functional outcomes as they relate to the goals listed. The discharge note is your final opportunity to justify that the skills of a therapist were necessary If the resident is hospitalized or expires the discharge note still must document the skilled services provided and the progress made during the episode of care. all of the above are accurate
6. ICD-9 codes on the evaluation should: Have both a numerical code and a descriptor Match what is in the medical record Accurately illustrate to Medicare why the resident is being treated in therapy All of the above
7. Pick the missing component in this goal: Resident will increase upper extremity strength to 3+/5 in two weeks. patient directed functional measurable time specific
8. Pick the missing component/s in this goal: in 2 weeks resident will sit upright in the wheelchair. patient directed, functional, measurable functional and measurable measurable and time-specific time-specific and patient-directed
9. Which of the following statements is false. Use of standardized tests and measures are recommended on the evaluation and throughout the episode of therapy care. For the plan of care, frequency should not be recorded in ranges (3-5x’s a week) Pain should be assessed on the evaluation and addressed throughout the documentation in both daily and weekly notes. An OT evaluation does not need to include an ICD-9 code
10. Which of the following statements is correct when looking at documentation guidelines for a medical record. Illegible signatures can lead to a denial in Medicare payment. Any abbreviation are allowable. White out can be used in a medical record. Write overs are acceptable.