Ch 8: Documentation Vocab Flashcards
Skilled Services
Requires services of professional training in the field of OT
Progress Report
Document that expresses progress towards goal achievement
Skilled Interventions
Involve the use of therapeutic use of self, occupation based activities and client, caregiver education…
Confidentiality
Protection of info that can appear in all forms of communications
Reimbursement
Regulations and requirements set up by a major payer source for the geriatric population
Long-Term Goal (LTG)
Overall functional outcome of the OT process
Clinical/professional Reasoning
Process used by OT practitioner to plan, direct, perform, and reflect on client care
Discharge Report
Written at conclusion of therapy program
Ethical Practice
Includes the 7 principles defined by AOTA to direct the OT practitioner in expected behaviors and expectations
Evaluation
Foundation upon which all components of client program are identified
Occupational Profile
Contains info gathered during an interview process
Assessments
Standardized/Nonstandardized ways of measuring and establish a baseline
Medical Record
Contains personal data and info relevant to the treatment of a patient, client, or person receiving medical treatment
Documentation
Necessary part of the OT process. Promotes professionalism and proof of value of intervention
Medicare Guidelines
Payments for OT services according to specific regulations and requirements
Short-Term Goal (STG)
Written for specific time frame and are specific to the accomplishment of the long term goal
OTPF-2
Occupational Therapy Practice Framework-2
Legal Document
Documentation that follows guidelines that will allow it to stand up in a legal investigation
HIPAA
Federal laws enacted to protect the consumer from breaches of confidentiality
Intervention Plan
Collaborative effort designed to establish goals and functional outcomes
SOAP notes
Subjective:what client tells you
Objective:fact info that is observed or measurable
Assessment:analyze and adjust
Plan:what to do next
SMART
Significant Measurable Achieve Relate Time-limited
RUMBA
Relevant Understandable Measurable Behaviorable Achievable
