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OTA 120 - Documentation > Documentation and Observation Basics > Flashcards

Documentation and Observation Basics Flashcards

1
Q

The WHO of documentation

A
  • You and anyone else providing care will contribute to the record.
  • Audience you are writing to (make understandable to all): Intervention team, insurance, caregivers/family, accrediting agencies, supervisors, lawyers, researchers, facility quality managers, etc.
  • OT documents overall evaluation; OTA may assist in eval process as delegated
  • OTA usually writes treatment/visit/daily note, and possibly progress note
  • OT must co-sign notes by OTAs/OTASs
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2
Q

The WHAT of documentation

A
  • What was done? Puts it in stone. What do you observe?
  • What was client’s reaction (physically/emo)
  • Demonstration of skilled services/complexity/education
  • Functional, client-centered, occupation-based
  • Clear, concise, activity able to be duplicated
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3
Q

The WHEN of documentation

A
  • As close to time of service as possible.
  • Sometimes point-of-service documenting
  • Often done when no clients being treated
  • Make at least brief notes throughout day
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4
Q

The WHERE of documentation

A
  • In each clinical setting, each client has his own clinical record/chart
  • May be computer, paper, or both
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5
Q

The WHY of documentation

A
  • To show what happened in chronological sequence
  • To show high level of clinical reasoning
  • To inform others on intervention team what happened
  • To demonstrate effectiveness of OT for third-party payers
  • For legal reasons
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6
Q

Questions to ask yourself when observing a client:

A
  • WHO is involved in treatment session?
  • WHEN did tx session take place?
  • WHERE did tx session take place?
  • WHAT happened during tx session?
  • WHY is the particular tx intervention important?
  • HOW did the client perform/participate in the task?
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7
Q

Why observation is important:

A

1) Observations used daily in treatments and help guide on continuing progress.
2) Observation is an important part of your clinical reasoning; you decide how to reach goals.
3) Helps improve your notes, gives clear mental picture of client’s situation and what transpired during the session. (Info to share.)

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8
Q

Using your EYES for observation:

A
  • Watch daily activities/ADLs
  • See body posture, skin appearance
  • Watch breathing patterns
  • See BMs/Urine (look for health issues)
  • Watch facial expressions/reactions
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9
Q

Using your EARS for observation:

A
  • Listen for raspy breathing/coughing/sneezing
  • Listen for crying, moaning, yelling
  • Listen for communication that is not speech
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10
Q

Using your NOSE for observation:

A
  • Breath
  • Body odor
  • Environment (chemicals? Gas?)
  • Urine/BM/Vomit
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11
Q

Using your TOUCH for observation:

A
  • Skin temperature
  • Skin texture
  • Pulse
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12
Q

Tips to look out for in Observation:

A
  • Does client guard for pain?
  • Is a supportive family member present?
  • What is quality of mobility/posture/function?
  • Are there cognitive/perceptual problems?
  • Is there pain?
  • Are there safety issues?
  • Are there issues with the environment?
  • Is progress being made? (Getting better?)
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13
Q

What Domain items affecting ability to engage in occupations are important to consider in documentation?

A
  • OCCUPATIONS: ADLs, IADLs, Rest/Sleep, Educ., Work, Play, Leisure, Social partic.
  • CLIENT FACTORS: Values/beliefs, Body functions, Body structures
  • PERFORMANCE SKILLS: Motor skills, process skills, social interaction skills
  • PERFORMANCE PATTERNS: Habits, Routines, Rituals, Roles
  • CONTEXTS/ENVIRONMENTS: Cultural, personal, physical, social, temporal, virtual
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14
Q

Swap for professional language:

  1. suffers from
  2. client did
  3. client walked
  4. client went up/down
  5. wheelchair ambulation
  6. gave client
  7. showed/helped client
  8. made
  9. changed
  10. looked at
  11. put
  12. brain-damaged
  13. weaknesses
A
  1. diagnosed with; has a diagnosis of
  2. client performed/ demonstrated/ engaged in/ worked on
  3. client ambulated/ performed functional mobility
  4. client ascended/descended
  5. performed wheelchair mobility; self-propelled wheelchair; ambulated while pushing wheelchair
  6. client was issued/ provided; Administered; Applied; Implemented; Received
  7. client was instructed; skilled instruction provided; training provided for…; Recommended
  8. fabricated/ customized/ designed/ developed
  9. modified/ adapted/ customized/ revised
  10. observed/ assessed/ evaluated/ examined/ measured for…
  11. positioned; set-up
  12. Diagnosed with TBI; Sustained closed head injury; Cognitive impairment/disability
  13. Challenges; Delayed skills acquisition
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OTA 120 - Documentation (12 decks)

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