Documentation Flashcards
AOTA definition of documentation
electronic and written forms demonstrating the skilled nature of the services provided, the professional reasoning of the occupational therapy practitioner and the justification for the services related to reimbursement and client outcomes
What is child find
Under IDEA part C it’s the way that the pediatrician does milestone checks to see if children are developing typically, if not they are referred for early intervention.
What is the process of documentation
Referral - child find
evaluation - multidisciplinary , supplimental ot
development of IEP or IFSP (POC)
notes - daily notes, progress reports
review or reevaluation
discharge or transition
IEP and IFSP does what for services
it is the big documentation and sets the framework for what the child needs.
electronic documentation includes what?
evaluation, session notes, progress notes, discharge
Requirements for documentation is specified by what federal law?
Federal - IDEA, FERPA, HIPPA
What are the non-federal law agencies that determine how we document?
State Education Agency
Local Education Agency
School Districts
Early Intervention Considerations
Lead Agency
- Sets policies and procedures
- Ensures IFSP developed within 45 days of referral
- State specific
Documentation
- Skilled occupational therapy
- Developmental progress
- Family engagement
- Child outcomes
Common Types of OT Documentation
Daily notes
Evaluation
—Preschool- Annual Review/Re-evaluation
Occupational therapy intervention plan (also known as plan of care)
Progress report
Contact Log
Transition report
Discharge report
What are some considerations for confidentiality
you can’t use your personal email.
What are some general considerations about documentation
Confidentiality
Electronic Documentation Platforms
Billing Procedures
–ICD-10 (Diagnostic Codes)
–CPT (Treatment codes)
State Practice Act & Education Based Documentation
What are the four main stops that governs what our documentation looks like
test scores
present level
strengths and needs
goals - needs and goals linked together.
According to medicaid criteria, Session notes needs to have….
Attendance and participation
—Services must be provided with student present
Must bill for a group if student is seen in a group
Date and time must be documented
Types of intervention implemented
Location of service
What is the first sentence
child was seen in ______ for a ____min session to address
Write in a manner that is neutral and positive, limiting the extent to which we emphasize deficits in our interpretation of observed behaviors”
what does this mean?
Be objective and not subjective
Not putting your own spin on it.
Don’t put feelings of reasons on kids.
Strength based model
Within this model, the role of intervention is helping families identify own strengths to assist with desired outcomes
Providers role in a strength based model:
Assist in identifying strengths
Developing outcomes collaboratively
Identify resources needed
Ways to determine that the outcomes are met
Descriptive notes in a strength based model
Wording or phrasing that objectively describes what the child or family says or does or what the clinician observes
Interpretive notes
Statements that describe a child’s behavior in a way that subjectively assigns meaning or interprets the behavior to mean something.
Interpretive notes in a strength based documentation has 3 parts
Positive, negative, neutral
positive interpretive
Suggests the behavior to be a strength or describes the behavior in an ability perspective
Negative interpretation
Suggests the behavior to be a deficit or describes the behavior from a disability perspective
neutral interpretation
Subtle quantifications (few, some, etc) without suggesting the behavior to be strength, deficit, problem or concern
Contact log
Any contact on behalf of the student must be documented
Education and training of school staff
Advocacy efforts to support student and family
Progress Reports
Typically embedded to EHR software
Provide summary of the intervention process
Documentation of progress towards goal achievement
Progress reports should include
Client information
Summary of occupational therapy services
Progress on goals
Plan or recommendations
Transition or Discharge
Early Intervention - Preschool -
Kindergarten
Collaboration with team members
Input to consider
Transition or Discharge?
