Documentation in Different Practice Settings Flashcards
What are some different practice settings?
- mental health
- school based
- SNF
- LTAC
- outpatient
- home health
Mental health documentation is more……
subjective
What kind of therapy is often used in the mental health setting?
group therapy
Problems in the mental health practice setting are usually divided into 2 parts. These are……
1) the problem itself (stated in 1-2 words)
2) a description of the behavior manifestations indicating the areas of occupation and underlying limiting factors involved
ITP
individualized treatment plan
the ITP is a ______ between the client and treatment team
contract
The ____ consists of problems, goals and interventions that are educationally based
IEP
exclusively problems of engaging in occupation in the education setting, even though the child may have deficits in other areas of life
functional problem statements
written for the duration of the school year, rather than using a timeline (like in goal writing)
goal statements
goals for the school year are called……
objectives
MDS
minimum data set
an assessment tool that considers all aspects of the client such as mood, mobility, ADL status, nutrition, pain, skin integrity…..
MDS
POC
plan of care
RUGs
resource utilization groups
____ are directly related to reimbursement
RUGs
