Chapter 1 : Documenting the Occupational Therapy Process Flashcards
WHO are we writing for & who are we writing about?
1) Intervention Team
2) Client/CG/Family
3) Facility Quality Management Personnel
4) Third Party Payers
5) Lawyers
WHAT are we documenting?
what happened……“painting of the OT session for the reader”
WHEN do we document?
As close to the time of service as possible……
WHERE do we document?
In the clinical record…….maybe be on:
1) computer
2) paper
WHY do we document?
1) to show what has happened
2) to show high level of clinical reasoning
3) to inform intervention team about what happened
4) demonstrate effectiveness of OT for insurance
5) for legal reasons
What kind of services require professional education, decision making and highly complex competencies?
SKILLED services
What kind of services are defined as those that are routine or maintenance types of therapy that could be carried out by nonprofessional personnel or caregivers?
NONSKILLED services
What are the 6 types of notes?
1) Initial Eval. Reports
2) Contact Notes (daily note)
3) Progress Notes
4) Re-evaluation Notes
5) Transition Notes
6) Discharge Notes
What type of note is when prior to any OT treatment, the client is evaluated to determine whether OT is appropriate and what kind of intervention will be used?
Initial Evaluation Reports
What type of note is when each time an intervention is provided by the OT, a notation is made of what occurred?
Contact Notes
What is the most common type of note?
Contact Notes
What type of note is written at the end of a specified period of time and includes client’s progress towards goals and details any changes made in intervention plan?
Progress Notes
What type of note is also known as “Reassessment” and is OT directed……
Reevaluation Notes
What type of note is done when a client is transferring from one service setting to another?
Transition Notes
What type of note is done at the end of treatment and is written to describe changes in client’s ability to engage in meaningful occupation?
Discharge or Discontinuation Notes
