Documentation in Different Practice Settings

Question 1

Documentation in School-Based Practice

Answer 1

Individualized Education Program (IEP)
* Consists of strengths, challenges, goals, and interventions
* If certain criteria are met, a state’s Medicaid program will reimburse schools for medically necessary direct services
* The IEP is a formal, multidisciplinary, written plan.

Question 2

IDEA REQUIREMENTS FOR GENERAL
CONTENT OF AN IEP

Answer 2

• A statement of the child’s present levels of academic achievement and functional performance
• A statement of measurable, annual academic and functional goals
  -benchmarks , progress, accommodations, and transitions

Question 3

Early Intervention

Answer 3

The five areas of child development addressed specifically in IDEA include
physical, cognitive, communication, adaptive (i.e., daily living skills), and
social/emotional.
* The law mandates that early intervention services must be provided in the child’s “natural environment,”
-A team of appropriate health disciplines evaluate the child and family and then meet with the parent

Question 4

Individualized Family Service Plan (IFSP)

Answer 4

• The IFSP is a multidisciplinary plan that is family-centered.
• Contains specific information about the child’s developmental status, family situation, and assessment results.
  OTs collaborate with members of the early childhood team to assist and partner with the family in overcoming the identified challenges and supporting occupational participation.
• Documentation must follow the requirements of the particular payer to
  substantiate the need for services and the skilled care provided.

Question 5

Acute Care

Answer 5

• Discharge planning often begins the day the client is admitted
  -When an order for occupational therapy is received, the OT begins
  the evaluation process and establishes the intervention plan.
  -contact notes are normally written by the OT or OTA

Question 6

Inpatient Rehabilitation Facilities: 3 Hours

Answer 6

An inpatient rehabilitation hospital must meet certain criteria to be classified as an inpatient rehabilitation facility (IRF) for reimbursement purposes

Question 7

Skilled Nursing Facilities

Answer 7

• Assessment Instrument (RAI) must be completed at specified intervals and is normally
  integrated with the EMR system in place
• Minimum Data Set (MDS) is a quality measure that considers all aspects of the client, such
  as mood, behavior, mobility, ADL status, bowel and bladder function, nutrition, pain, skin
  integrity, etc.

Question 8

Medicare B Documentation

Answer 8

• OT services must be reasonable and necessary for the client’s condition and
  situation and substantiated in the record .
• Documentation is required for every treatment day, and every therapy service.
• OT gathers pertinent client information and selects measures to evaluate the client.
• establishes an intervention plan, which Medicare refers to as a plan of care (POC)

Question 9

Home Health

Answer 9

• The client’s physician must establish and approve a specific plan of care for all skilled services the client with Medicare will receive

Question 10

Home Health: OASIS

Answer 10

The method used to collect the required data is called the Outcome and Assessment Information Set (OASIS).
* Completed at the start of care, recertification periods, client transfer to another facility, and at discharge or
death.

Question 11

• Contact notes must include the following elements

Answer 11

Changes in client’s status/response to prior treatment, pertinent factors
assessed
* Clear, objective description of the skilled services implemented
* Description of immediate response to treatment by client/caregiver
* Specific plan for next visit or immediate follow up needed

Question 12

Mental Health

Answer 12

Reimbursement may not be discipline-specific and therapy services may be
included in the comprehensive daily rate for the facility.