Chapter 17 Flashcards
The medical record is a ______ record
Legal
Everyone who provides pt svcs and records info may be held accountable for the quality of tx rcvd based on what?
Documentation
In these tips of records, each source or clinical discipline such as nursing or OT, documents info in a separate section of the chart
Source oriented and integrated records
In this type of record, The notes are organized into smaller sections, each for a different discipline
Source oriented
In this record, all the notes from different disciplines are in one section
Integrated record
Because of problems with source oriented and integrated records, like chronological documentation this type of record came about
Problem oriented
Who came up with the problem oriented medical record?
Lawrence Weed
POMR
Problem oriented med record
The POMR is organized into three major sections. What are they?
Database
Problem list
Reports of plans and progress
This part of the POMR is developed in the first 48 hours of hospitalization or outpt tx. It contains the same info as what might be included in the admission report.
database
This part of the POMR is developed from the database. It identifies all of the pt’s problems.
problem list
This section of the the POMR discusses reports of plans and progress
Reports of plans and progress
____________ reports identify the assessments that were used, the results of these assessments, the therapist’s interpretation of the results, and the therapist’s tx plan
Eval
The __________ plan spells out the goals established, the methods to be used, the frequency of tx, and the time by which the therapist expects the goals to be reached.
Intervention
A _______________________ documents individual OT sessions or contacts and the service provided.
contact, tx, or visit note
A ______ report documents tx periodically, updating info on progress toward functional goals, changes to the plan, and coordination of care.
progress
A __________ report documents the results of the reevaluation, compares these to the initial eval, and recommends changes or continuations in the plan.
reevaluation
A _________ plan is written in preparation for a move from one setting to another
transition
A ___________ report gives a concise description of the entire course of OT intervention since first contact and includes assessment of outcomes
discharge or discontinuation
This type of report documents the facts of an emergency in which, for example, a pt was injured or eloped while under the supervision of an OT staff member.
critical incident report
Two other letters a COTA may write include _.
appeal letter and letter of advocacy (to speak on behalf of pt, group, or population)
The COTA keeps records on each tx service he or she provides. Sometimes this is referred to as a ____________ (think of trees).
therapy log
