Doc Exam 2 Flashcards
Suggestion, No federal rules
Referrals
Referrals are received based on
State licensure and payor policy
When to refer to others
Outside of our knowledge base, personal issues, others w/ expertise
AOTA prefers term
physician referral
Substitute for order
Can be specific or very broad
Care plans/treatment plan
Medicare requires recertification every
30 days for outpatient (60 for homecare)
Referral includes
Full name/client
Date
Reason for referral (dx)
Full name and physician signature
Frequency/duration (can include intensity/length of session)
brief check to see if client needs further eval, referral, or intervention
Not reimbursable
Can be done without physician order/referral
Screenings
routinely screening individuals in a particular setting
Type 1 screen
screening after referral has been received
Type 2 screen
Screen CAN/CANNOT be subbed for an eval?
Cannot
Screen CAN/CANNOT be a component of eval??
Can
Guidelines of screening system:
Within scope
Timely
Understanding of population
Intervention should be available
Valid/reliable methods (does not mean standardized)
4 Possible outcomes of screen:
- Needs OT
- not severe enough to warrant OT
- Out of scope
- Doesn’t need anything
In screenings a COTA can…
Assist and report recommendations
brief note in the medical record
May be used to document….
Order/referral received
Screen was performed
Communication between OT and COTA
Recommendation for equipment
Recommendation of family or caregiver or training
Missed visits
Contact note
most impairment doc to OT; client centered and evidence based
All other documents/actions follow
Must show need for OT services; “medically necessity” “educationally relevant”
Must demonstrate the clients function presently and previously (prior to intervention)
Evaluation
process
Evaluation
Tool
Assessment
Describe current level, predict future function, measure for baseline
Evaluation
T/F: You do not have to provide intervention but you do have to apply evaluation
True
Examples of how an eval should describe any unique circumstances:
Previous injury, Context, Emotional issues, Inconsistency
performance first
Kolhman, TOGGS, school functional assessment, ADL
Top down eval
client factors first
Berg, DTVP3, ROM, MMT, ACL
Frame of reference must go w/ eval
Bottom up eval
ID info (Dx, name, age)
Reason for referral
Referral source
Previous tools/test
Precautions/contraindications
Appropriate dx?
Occupational profile
How results affect occupational performance
Consistency b/w results and behavior
Components of Eval
looks @ everything
Comprehensive eval
Example of Problem specific eval
DASH, ADL assessment
Example of standardized eval
peabody
Not standardized eval
reflexes, clinical experience/observation
Informal eval
cognition interaction, orientation
Activity based eval example
ACL, FCE
Things to consider in evaluations
Personal development
Context
Relationship
Occupational performance
Development and occupational relationships
Things to remember in evaluations
Ongoing and dynamic
Bias, expectations, and prejudices
Client/family perspective
Completed eval should depict client well
responsible for the process
Choosing appropriate eval
Summarizing, analyzing and interpreting
Developing the intervention plan
Referring to another party or profession
writes the Plan
OTR role
can contribute, perform parts or components
Give input
COTA role
This role can Educate and explain evaluation to family or client
Both COTA and OTR
Paves the way to justify your plan
Show OT as necessary
How you report and interpret
constant
Informal or formal
Re-eval
every time you see the client
May result in changes to care plan or treatment
Don’t charge
Informal re-eval
depends on payer and facility and you
May result in changes or show progress and justify continuation
Can usually charge
Facility, payor source, protocol of test, doc visit, major change, adding goals
Formal re-eval
May or may not include the goals
Describes what is going to happen during the therapy process
Collaboration between: OTR, COTA, Client
Intervention Plans
Treatment plans
Medicare Criteria:
Must functionally improve
Reasonable time
Not maintenance
Not spontaneous
The cota can change these but not the goals
The COTA may choose which ones (following accepted practice and protocol) to use on which days, but she/he can’t add or choose to delete items-only the OTR can do that
Activity
Things to do when there’s no progress
Explain why: Barriers, What you have done about them
Explain the new plan ( if there is one) or discharge with recommendations
Should reflect: Individual, group , consult ect
Goals must be
Measurable - Objective
Functional - This makes us OT
Achievable - Not too easy, Not too hard
Guide the treatment interventions
Let us know when to discharge
Give a method for assessing the effectiveness of the intervention
Goals
Goal Directions: How do we know what type to use?
Frame of reference you are using
Setting
OT Framework
shoulder ROM will increase to 180° to be able to hang laundry
Biomechanical goal
Pt will reach overhead to hang clothing without scapular elevation
NDT goal
Pt will hang 10 pieces of laundry in 5min
Task oriented goal
Types of goals
Restorative
Habilitative
Maintenance
Modification/Compensation/Adaptation
Preventive
Health Promotion
Restore previous occupational performance
Restorative
Teach new occupational performance skills
Habilitative
Keep current occupational performance skills
Maintenance
Change contexts or activity demands to enable occupational performance
Modification
Prevent occupational performance deficits from developing
Preventive
Enrich or enhance occupational performance skills
Health promotion
Overarching
When to discharge
Discharge goals
Objectives
Long Term - LTG
May change as the client progresses or fails to progress
STG - Specific time (days, weeks , visits)
Formats
ABCD
COAST
RHUMBA
SMART
How to make them measurable
Frequency or consistency
Duration
Assistance
Quality
Level of complexity
Participation
Others
Decrease in behaviors
