Documentation Flashcards
1
Q
The 6 Cs of why we document
A
- Chronological record • Compliance • Communication • Clinical reasoning • Collection of data • Courtroom defense
2
Q
How can lawyers Use Your Documentation?
A
- Chronology of events
- Credibility
- Competence
- Bias
- Carelessness
3
Q
Each step of the OT process is documented. What are they?
A
Initiation of service (Referral or order Contact note)
Evaluation (Evaluation report)
Intervention planning (Intervention plan)
Intervention (Implementation, Contact note, Progress report)
Discontinuation of services
