Documentation

Question 1

what are the purposes of documentation?

Answer 1

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

Question 2

what are the different types of documentation?

Answer 2

Evaluation & Intervention Plan
Contact, Progress Reports, Transitional Plan Note
Discharge, Discontinuation Note

Question 3

what type of document is a medical record?

Answer 3

legal document

Question 4

what are the requirements of medical record notes?

Answer 4

must be signed by provider and include credentials

Question 5

what are the requirements of the medical record entries?

Answer 5

specific, complete, truthful, timely, objective & reflect actual care provided

Question 6

what are other guidelines for the medical record?

Answer 6

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

Question 7

how does Reimbursement & Documentation ensure payment?

Answer 7

documentation must met requirements of third party payers

Question 8

what do care plans require for reimbursement in regards to goals?

Answer 8

ST and LTGs goals that are functional and measurable and realistic

Question 9

what must Treatment notes illustrate for reimbursement?

Answer 9

progression towards goals

Question 10

what type of tx should be provided for proper reimbursement? what should be avoided?

Answer 10

Skilled and restorative tx

Duplication of services should be avoided

Question 11

what should be determined when documenting LTG’s?

Answer 11

What final outcomes do you expect patient to achieve at the time of d/c from your program

Question 12

what should LTG’s focus on?

Answer 12

Functional Outcomes
Project time frame
Revise LTGs prn

Question 13

what should be determined when documenting STG’s?

Answer 13

What “mini” outcomes are necessary to achieve the long-term goals

Question 14

what should STG’s focus on?

Answer 14

underlying factors that are interfering with function; relate these underlying factors to functional deficits

Project time frames; revisit time frames prn
Revise STGs prn

Question 15

what words should be avoided b/c they dont reflect progress?

Answer 15

Status Quo
Goals (or plans) unchanged
Little or no change noted
Making slow progress

Question 16

what words should be avoided b/c they dont reflect potential for improvement ?

Answer 16

Unmotivated/not motivated
Minimally participates
Uncooperative
Patient refuses
Poor potential
Unable to participate
No change in status noted

Question 17

what words should be avoided b/c they dont support need for skilled therapy?

Answer 17

Practicing
Continues to perform
Observed performing

Question 18

what should documentation include when using physical agent modalities (PAM)?

Answer 18

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

Question 19

What should documentation include when using assistive/adaptive devices and orthotics?

Answer 19

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

Question 20

what should OT consider when Documenting for funding for wheelchairs & assistive technology?

Answer 20

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

Question 21

what should OT do to properly document requests for funding?

Answer 21

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

Question 22

what terms should you use when trying to get funding in medical settings?

Answer 22

Medically necessary, part of treatment plan, reasonable, will increase independence and reduce burden of care

Question 23

what terms should you use when trying to get funding in vocational settings?

Answer 23

Enhance vocational potential, assist with return to work (especially previous employment), enhances employability, and promotes independent living

Question 24

what terms should you use when trying to get funding in educational settings?

Answer 24

Educationally relevant, needed in order for child to receive education in least restrictive environment, providing related services consistent with IEP