Documentation Flashcards
HIPAA
Heath Insurance Portability and Accountability Act. Includes the Privacy Rule
Privacy Rule
Allows health care providers to share information regarding their clients yet still protect this sensitive information from the general public
SOAP notes
Used for communicating daily or weekly information within facilities.
“S” in SOAP note stands for what?
Subjective- what has been said by the pt
“O” in SOAP note stands for what?
Objective- observable and measurable data from evaluation and treatment results
“A” in SOAP note stands for what?
Assessment- Opinion, interpretation or assessment of the results of client’s functional performance and anticipated outcomes including problem list and long- and short-term goals
“P” in SOAP note stands for what?
Plan- the treatment plan including frequency and duration of treatment
Less structured than SOAP notes, these can be used to document client contact that is not necessarily during treatment
narrative notes
Level of assistance when pt requires no assistance or cueing in any situation and is trusted in all situations 100%
independent
Level of assistance when caregiver is not required to provide any hands-on guarding but may need to give verbal cues for safety
supervision
Level of assistance when caregiver must provide hands-on contact guard to be within arm’s length for client’s safety
contact guard/standby
Level of assistance when caregiver provides 25% physical and/or cueing assistance
Minimum assistance
Level of assistance when caregiver assists client with 50% of the task
Moderate assistance
Level of assistance when caregiver assists client with 75% of the task
Maximum assistance
Level of assistance when client is unable to assist in any part of the task
dependent (Total assist-TA)
Form of documentation that is typically in the form of a grid
flow sheet
Four main components of functional outcomes
- Must Address performance
- Must have measurable data to indicate when outcome has been met
- Needs to specify specific conditions under which the performance should be completed
- Needs to give a time frame for completion
What is the 8-step process of clinical reasoning for documentation?
- After referral to OT and eval, predict functional outcomes on the basis of groups of people with similar problems
- Consider the client, present and past functional abilities, and occupational history. Collaborate with the client on activities that are meaningful and achievable. Set client outcomes.
- Observe performance
- Establish a sequence for short term objectives
- Consider the timing of outcomes and short-term objectives, and prioritize and sequence treatment methods
- Reassess performance and complete daily and/or weekly notes
- Reexamine outcomes and short-term objectives, and complete the monthly summary
- Complete discharge summary
Initial evaluation report is divided into what 4 sections?
- Description of the ct’s occupational PROFILE
- Analysis of the ct’s occupational PERFORMANCE
- PRIORITIZING areas of occupation and occupational performance
- Intervention PLAN
Daily notes
Brief and reflect the treatment provided, the client’s response to treatment, and progress noted
Progress notes
required on a weekly or biweekly basis.
This describes the client’s final status on discharge from the facility
discharge summary
This pays for hospital inpatient, SNF, home, and hospice care
Medicare part A
This pays for hospital outpatient, physician, and other professional services
Medicare part B
