Chapter 17 : Medical Records and Documentation Flashcards
What is the most important task of the OT practitioner?
Documentation
What are the 2 approaches to organizing notes?
1) source-oriented record
2) Integrated record
Notes are organized into smaller sections, each for a different discipline, so for example, all the OT notes are in one place
Source-oriented record
All of the notes from different disciplines are in one section; the notes are written one after the other
Integrated record
When was the problem oriented medical record (POMR) introduced?
1969 by Lawrence Weed
The problem oriented medical record (POMR) is organized into 3 major sections…….
1) the database
2) the problem list
3) the reports of plans and progress
Identifies the assessments that were used, the results of these assessments, the therapists interpretation of the results, and the therapist’s treatment plan - the emphasis is on obstacles to the clients’s engagement in occupation
evaluation reports
Spells out the goals established, the methods to be used, the frequency of treatment, and the time by which the therapist expects the goals to be reached
intervention plan
Documents individual OT sessions or contacts an the service provided
contact, treatment, or visit note
Documents treatment periodically, updating information on progress toward functional goals, changes to the plan, and coordination of care
progress report
Documents the results of the reevaluation, compares these to the initial evaluation, and recommends changes or continuations in the plan
reevaluation report
Written in preparation for a move from one setting to another - summarizes all pertinent info and recommendations
transition plan
Gives a concise description of the entire course of OT intervention since first contact and includes assessment of outcomes
discharge or discontinuation report
