Translation of Notes Into Plain English

Pacific University School of Occupational Therapy

Translation of notes into plain English:

Do the following exercises in your textbook. Answers to these exercises are provided in Appendix F-your online resources.

Exercise 2.1 & 2.2 (page 10-11) Asking you to use SBAR to organize your communications concerning a client.

Exercise 3.2 (page 36) Translate one of the two notes presented into plain English..

Exercise 4.1 (page 46)

Quiz Questions:

Abbreviations are acceptable to use in practice. T

The correct abbreviation for “four times the day” is: qid* prn bid noc

The abbreviation OTD/L stands for: Doctor of Occupational Therapy, Licensed* Occupational therapist, Doctor of Occupational therapist registered Overdose

What does the abbreviation MSQ stand for? Mental status questionnaire* Multiple sclerosis questionnaire Master of social work practitioner Multiple sequential qualities

Which of the following are not “red flag” words? Continued OR Maintain Unmotivated Stroke victim Terminates

Which of the following accurately reflects a reason that clients who set goals achieve better outcomes that those who do not? Having a therapist set goals for a client helps to focuses a person’s attention and directs his/her efforts Establishing challenging, and slightly unrealistic, goals leads to greater effort and persistence Setting goals that are just below a persons’ ability leads to higher performance vs. just encouraging the person to do their best. Goal achievement requires on-going feedback that recognizes the person’s progress toward the goal.*

What does SBAR stand for? It is an acronym for: Situation, Background, Assessment, Recommendation* Statement, Backround, Assistance level, Record Subject, Behavior, Assessment, Relevance

What is the purpose of using SBAR for communication? Organization of communication for clarity* Relating quality of practitioner-client interaction Referring document for use of abbreviations Detailing progress in rehabilitation

Of the 15 essential elements for documentation, how many of the essentials relate to compliance with laws, confidentiality, errors, disposal of records, or storage? Five* Four One Six

According to the 15 essential elements of documentation, is a co-signature required for student documentation? Yes* No

How will people judge your professionalism? By how well you: Dress Speak Write* Behave

In clinical settings what gets documented? The client’s needs and wants Each step of the OT process* Intervention activities Results of ongoing evaluations and interventions

Documentation that is necessary but NOT related to the delivery of care to clients is called: Stenography Administrative documentation* Academic documentation Management documentation

What should you avoid in professional communication? Profanity, slang, and contractions* Notations, objectivity, profanity Slang, Structure, and subjectivity Contractions, contraindications, familiarity

What is the most important consideration in professional communication? Tone* Nondiscriminatory language Familiarity Active voice

Which of these sentences is written in passive voice? The client is afraid of falling, which puts the client at greater risk of falling. The fear of falling has been the factor with the greatest impact on the client.* He has been afraid of falling, limiting his mobility in his community. The client broke his hip by falling.

Is it ever appropriate to refer to occupational therapy practitioners as “Therapist.” Yes, always Yes, but only if you are referring to occupational therapists Yes, but only if you’re referring to occupational therapist you know personally No*