Importance of Documentation

When should documentation be created?

• After an intervention is completed

• Before an intervention starts

• During a day off

• All of the above

What is a necessary component of documentation?

• Clarity

• Ambiguity

• Complexity

• Vagueness

What is an ethical issue in documentation? Choose two

• Privacy concerns

• Increased efficiency

• Enhanced collaboration

• Improved accuracy

What is a benefit of using a specific format for documentation?

• Consistency

• Inconsistency

• Confusion

• Disorganization

How can documentation affect legal proceedings?

• By providing evidence

• By creating confusion

• By reducing clarity

• By increasing ambiguity

What is a reason to document missed sessions?

• To find out why

• To make the patient feel bad.

• To ignore the issue

• To create a playlist

What type of documentation is required according to the OT standards of practice?

• Informal notes with signature and credentials

• Personal notes and thoughts

• Appropriate documentation according to state and facility standards

• Verbal agreements

What is a common mistake to avoid in note-taking?

• Using clear language

• Including criticisms

• Correct spelling

• Objective information

What should be avoided to keep notes professional?

• Clear writing

• Criticisms, judgments, or diagnoses

• Correct grammar

• Objective information

What does the "S" in S.O.A.P. stand for?

• Subjective

• Standard

• Summary

• Solution