Administrative Documents Flashcards
Administrative documents may include…
Incident reports
Productivity reports
Employee evaluations
- COTA eval
Staffing reports
- To justify needing more staff
Appeals letters
- For documentation that gets kicked back
Supply orders
Grants
Policy and procedures
When are incident reports done?
When there is an injury or incident (injury or potential injury) occurs to an employee, a client, or a client’s family or friends.
Reasons you might do an incident report
Client falls out of bed at night
Client falls during a transfer attempt
Client cuts hand with leather knife during craft group
Family member trips and falls walking into clinic
Clients child sticks finger in the wheel of the exercise bike and tears nail off
Therapist is hit in the head with a dressing stick
Components of an incident report
Description of incident
- Very detailed
Signature and/or witness accounts
Medical intervention if any
Reviewed by administrator or risk manager and signature
- OT may be risk manager, particularly in industrial rehab
Does the incident report go in the medical record?
NEVER
Don’t mention it either
Not part of discovery or normal disclosure
It is not a medical document
Do you include incident report with daily note?
Daily note is less specific, may allude to a problem
“Therapy was discontinued when patient became aggressive toward therapist and threw the phone at her”
What are the red flags for billing denials?
Wrong codes
Codes don’t match
Too vague
Not medically necessary
Outside of policy
What do you do once you have a denial?
Find out why
- They may simply tell you
- Remember the intermediary can interpret but not create policy or law
- “We don’t pay for OT for leg injuries, only UE injuries”
> Ask to see the policy
Be respectful and use as an opportunity to educate, you might can make a deal
Amount of time
- Medicare 120 days
- Others vary
What is the difference between policy and procedure?
Policy: how the organization feels about a topic, statement
Procedure: steps, how the policy is followed
The policy includes…
The policy statement
The effective date
Those affected (may be everyone, general)
Responsible party
Purpose
Procedure
Can policies change?
yes
At what level will policy affect you?
In your own facility
- OT can’t adjust equipment
Local level
- School district has policy of not using OT
State level
- Georgia says ATCs can use PAMS
National level
- National medicine
- Medicare cuts
How do you do something about policy formation?
Grass roots
Licensure board
State association
National Associations
Other Associations
- Those with OT ties: CHT, SI groups ect
- Those who are in the medical community: PT, AMA
Professional documentation you might participate in
Quality Control
Documentation review
Meeting and minutes
What should be included in meeting minutes?
Synopsis of what was said, not what should have been said
Word for word is not necessary
