Podcast
Questions and Answers
In a SOAP note, where would you document a client's report of feeling anxious?
In a SOAP note, where would you document a client's report of feeling anxious?
- Objective
- Assessment
- Subjective (correct)
- Plan
Which charting system is primarily used to track client progress related to specific, identified problems?
Which charting system is primarily used to track client progress related to specific, identified problems?
- Focus Charting (correct)
- Narrative Charting
- BIRP Charting
- SOAP Charting
What is the primary purpose of a discharge summary in recreational therapy?
What is the primary purpose of a discharge summary in recreational therapy?
- To provide a checklist of activities completed
- To document billing information
- To provide daily notes of client progress
- To summarize the client's course of treatment, outcomes and recommendations (correct)
Which of the following is NOT considered a 'do' of charting in recreational therapy?
Which of the following is NOT considered a 'do' of charting in recreational therapy?
When using a time sampling observation system, what is the primary focus?
When using a time sampling observation system, what is the primary focus?
In the ENCOURAGES acronym, what does the 'G' stand for?
In the ENCOURAGES acronym, what does the 'G' stand for?
What is the key difference between FIM and Section GG assessments?
What is the key difference between FIM and Section GG assessments?
If a therapist is using a reflection of feeling as a clinical skill, what might they say to their client?
If a therapist is using a reflection of feeling as a clinical skill, what might they say to their client?
Flashcards
SOAP Charting
SOAP Charting
A method of charting using specific categories: Subjective, Objective, Assessment, Plan.
Problem Oriented Medical Record (POMR)
Problem Oriented Medical Record (POMR)
A system of charting focused on patient problems. It utilizes a problem list, interventions and assessment of progress.
Focus Charting
Focus Charting
A system of charting primarily focused on the patient's chief complaint.
Narrative Charting
Narrative Charting
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Behavioral Checklist
Behavioral Checklist
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Interval Recording
Interval Recording
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Duration Recording
Duration Recording
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Discharge Summary
Discharge Summary
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Study Notes
Study Guide for RCTX 3254 Test 2
- The exam will be multiple choice and matching questions
- Material covered in class, readings, and handouts is fair game
- Review assigned readings on Canvas
Documentation & Progress Note Writing
- Know different charting systems (types, benefits, characteristics)
- SOAP, BIRP, Focus Charting, Narrative Formats
- Understand Do's and Don'ts of charting
- Best practices in charting
- Know what "meaningful data" is for charts and appropriate locations for different data types
- Recognize different documentation systems
- Identify structural errors in progress notes
Behavioral Observation
- Know different observation systems and their use cases
- Know how to calculate behavioral observation reliability
- Improve observation reliability techniques
- Know target behaviors
- Understand different types of observation systems and when to use them based on observed behavior
Clinical Interviewing Skills
- Understand the concepts of attending and listening
- Know the ENCOURAGES acronym and types of clinical skills
- Identify different clinical skills in an applied scenario
- Know how to use notetaking and scripts in clinical interviews.
Discharge Summaries
- Know the purpose of DC Summaries
- Know components of a DC Summary
- Understand healthcare trends and the need for DC Summaries/outpatient Summaries
- Know how DC Summaries impact RT services
Section GG & FIM
- Know the rating levels of Section GG and FIM
- Compare and contrast Section GG and FIM
- Understand why the new Section GG was developed
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Description
Prepare for the RCTX 3254 Test 2 with this comprehensive study guide. Covers crucial topics including charting systems, documentation best practices, behavioral observation techniques, and clinical interviewing skills. Review key concepts and ensure you're ready for multiple choice and matching questions.
