DOCUMENTING DIFFERENT STAGES OF INTERVENTION

Question 1

CONTACT NOTE

Answer 1

-Used to document each encounter or OT session
Can include face to face contact, or telephone
- visits
- Written each time a client is seen
- Frequency, format, and content vary among practice
settings
-Guided by payer requirements and applicable laws

Question 2

CONTACT
NOTE
CRITERIA

Answer 2

• Client information
• Therapy log
• Intervention/procedure coding
  (CPT), if applicable

Question 3

PROGRESS REPORT/NOTE

Answer 3

• Written on a regularly scheduled basis (weekly, bi-weekly, monthly)
• Guidelines set by primary payers
• Provides a summary of the intervention process and record of the client’s progress toward goals
• Criteria include:
  1. Client information
  2. Summary of services provided
  3. Current client performance
  4. Plan or recommendation

Question 4

RE-EVALUATION REPORTS

Answer 4

• May occur monthly, quarterly, or on an as-needed basis
• OT is responsible but certain functions may be delegated to the OTA
• Includes new information about the client’s condition
• Outcome measures from initial eval are re-administered
• Revisions to the goals and plan are made as appropriate
• New timelines
• The OT may also make recommendations or referrals

Question 5

TRANSITION PLANS

Answer 5

Developed whenever a client transfers within a service
* OTA does contribute to this process
* Provides client information to the new service providers
* Summarizes the client’s current occupational status,
* Lists what follow-up or services would benefit the client

Question 6

DISCHARGE REPORT

Answer 6

• Synopsis of the client’s changes or progress from SOC
• Responsibility of the OT but parts may be delegated to the OTA
• Content includes date and purpose of the referral; summary of the client’s condition; comparison of initial eval findings to discharge
  status; summary of course of treatment
• Also includes progress and outcomes and recommendations for
  follow-up

Question 7

REASONS FOR DISCONTINUING OT

Answer 7

• OT outcomes were met
• Client discharged from facility/agency
• OT is no longer medically or educationally necessary
• Duplication of services
• Client not making progress
• Client was hospitalized
• MD discontinued therapy
• Reimbursement issues