Documentation Flashcards
what are the purposes of documentation?
to have written record of tx to monitor progress and outcomes? to share info with tx team reimbursement research for activities to meet legal, public health requirements
what are the different types of documentation?
Evaluation & Intervention Plan
Contact, Progress Reports, Transitional Plan Note
Discharge, Discontinuation Note
what type of document is a medical record?
legal document
what are the requirements of medical record notes?
must be signed by provider and include credentials
what are the requirements of the medical record entries?
specific, complete, truthful, timely, objective & reflect actual care provided
what are other guidelines for the medical record?
Use only approved medical abbreviations
Pts can access their medical record by following facility procedure
HIPAA regulations apply
Avoid interdisciplinary “fighting” in the medical record
how does Reimbursement & Documentation ensure payment?
documentation must met requirements of third party payers
what do care plans require for reimbursement in regards to goals?
ST and LTGs goals that are functional and measurable and realistic
what must Treatment notes illustrate for reimbursement?
progression towards goals
what type of tx should be provided for proper reimbursement? what should be avoided?
Skilled and restorative tx
Duplication of services should be avoided
what should be determined when documenting LTG’s?
What final outcomes do you expect patient to achieve at the time of d/c from your program
what should LTG’s focus on?
Functional Outcomes
Project time frame
Revise LTGs prn
what should be determined when documenting STG’s?
What “mini” outcomes are necessary to achieve the long-term goals
what should STG’s focus on?
underlying factors that are interfering with function; relate these underlying factors to functional deficits
Project time frames; revisit time frames prn
Revise STGs prn
what words should be avoided b/c they dont reflect progress?
Status Quo
Goals (or plans) unchanged
Little or no change noted
Making slow progress
what words should be avoided b/c they dont reflect potential for improvement ?
Unmotivated/not motivated
Minimally participates
Uncooperative
Patient refuses
Poor potential
Unable to participate
No change in status noted
what words should be avoided b/c they dont support need for skilled therapy?
Practicing
Continues to perform
Observed performing
what should documentation include when using physical agent modalities (PAM)?
MD order Evidence sensory assessment was completed Purpose Specific location applied Application method Length of time of application If appropriate, skin check before, during, after application Effectiveness of PAM
What should documentation include when using assistive/adaptive devices and orthotics?
Name/purpose of device
Amount of assistance needed to don/doff device
When should device be used/ wearing schedule
Precautions - be specific
Care of device, e.g. method of cleaning, storage
Special instructions
Phone # to call for follow-up
“Return Demonstration”- to whom and results
what should OT consider when Documenting for funding for wheelchairs & assistive technology?
Pre-authorization often required Plan/Think ahead about equipment needs Know requirements for funding agencies Use appropriate forms Documentation should clearly justify why client needs the equipment; include objective findings/picture if necessary
what should OT do to properly document requests for funding?
Use appropriate forms Include accurate/complete info Therapy evaluation and results, including relevant diagnostic reports MD prescription Use evidence based support A picture speaks a thousand words If denied try again
what terms should you use when trying to get funding in medical settings?
Medically necessary, part of treatment plan, reasonable, will increase independence and reduce burden of care
what terms should you use when trying to get funding in vocational settings?
Enhance vocational potential, assist with return to work (especially previous employment), enhances employability, and promotes independent living
what terms should you use when trying to get funding in educational settings?
Educationally relevant, needed in order for child to receive education in least restrictive environment, providing related services consistent with IEP
