Documentation Flashcards
What is the documentation process?
Consult Screening Referral for eval and treatment Evaluation Treatment plan Progress notes Discharge summary
What is documentation and it’s purpose?
A professional document that: Verifies treatment Represents clinicians reasoning Reflects specific information Acts as a communication tool Is required for reimbursement
What are the different types of evaluation documentation?
Narrative
Checklist
Fill in blanks
Computerized
What are the components to an evaluation doc. ?
Clients name Med record number DOB Dx Reason for referral PMH allergies Medications Home environment Clients goals Current date Observations Assessments Results/interpretations Recommendations Frequency and duration Signature/date/time
What four factors make up service delivery?
Who will perform it? OT/COTA?
how often? 2-3x weekly
Amount of time for each session
Duration
What makes up a goal?
Behavior
Condition-how
Criteria-how well
Time frame
What is the intervention review?
Review of current treatment to be able to document progress towards goals
Essential for reimbursement
What is the purpose of discharge documentation?
To reflect progress from initial evaluation to final status or the need to stop treatment due to a lack of progress
Include further recommendations for other services- HEP, another practice setting
What should be included in documentation for reimbursement?
ICD9/10 codes, CPT codes, G codes, L codes
What is the documentation critical pathway?
A multidisciplinary plan that outlines adult treatment, goals, objectives, and educational needs for the client across all disciplines within a given time period
Provides consistent care across the disciplines
Who can read documentation?
MD, nurse, case manager, social services, supervisor, client and approved family, insurance, team members, lawyers, accreditation agencies
What is the relationship between reimbursement and documentation?
Documentation is a means for 3rd party payers to determine payment for services
Reimbursement varies according to the contracts set up through the organization
Each 3rd party payer has specific criteria for the approval of OT services, # of visits allowed, requesting additional visits, follow up recommendations, and justification for equipment/splints
What is a SOAP note?
Subjective, objective, assessment plan
A type of progress note
Quick review of the clients status prior to intervention
what is the subjective detail of the note?
The clients report/perceptions
“Client stated…”
What is the objective detail of the note?
Factual/professional information provided by the therapist
Baseline data, progress on goals,observations
“Client was seen for…” “The intervention consisted of..”
