FOR Flashcards
Describe the top down approach.
Documentation will focus on the function
“Mr. Jones demonstrated the ability to wake his self, dress and come to breakfast on time today”.
When completing an evaluation on a CVA if you approach it by doing the occupational profile first, this is top down
Occupation based, task-oriented, environmental, MOHO
Describe the bottom up approach.
Documentation will focus on the performance skill (but as OT’s we always look at function)
“Mrs. Little presents with moderate edema and level 3/10 pain, her AROM is limited to 50%”
Even though this is common in some settings the OT Profession prefers the TOP DOWN approach!
Biomechanical, remedial/motor learning, PNF, developmental
What is the focus in industrial rehab?
job performance
Task oriented, occupation based, rehabilitative, remedial, developmental
What is the focus in inpatient rehab?
ADLs and levels of independence
occupational adaptation, task oriented, biomechanical, occupation based, remedial, rehabilitative
What is the focus in psych?
daily function, interactions with others, behavior
CBT, task oriented, behavioral models, possibly cognitive models depending on their cognitive level, occupational adaptation, rehabilitative, MOHO, PEO
What is the focus in school?
academics
developmental, task oriented, behavioral, occupational adaptation, learning and teaching
What is the focus in home-care?
safety and personal ADLs
PEO, CMOP, EHP
What are the 2 primary types of documentation records?
POMR - problem oriented medical records
SOMR - source oriented medical record
Describe POMRs.
Each problem is given a number
Usually developed by the team
Documentation follows each other addressing the specific problem
Describe SOMRs.
Each discipline has a section
Most common
Describe the SOAP note.
(S)ubjective: what the patient said and what you subjectively saw or heard
(O)bjective: the facts, what you did with the client and the factual performance
(A)ssessment: what you as a professional think about the situation, or your interpretation of what is going on; improvements
(P)lan: what you are going to do next, your expectations or goals for the client
- include frequency, duration, and sometimes intensity
What is a skilled service?
A service that requires specialized education or skills to perform, can not be performed by an untrained individual
Medicare and BCBS: only OTR, COTA, PT, PTA, and SLP are considered specialized services
How do you make dressing a skilled service?
Educate client on adaptive equipment
Exercise/functional ROM to promote I.
Manually assist (HOH)
Teaching/instructing/demonstrating adaptive techniques to facilitate I with dressing
“Pt was instructed in dressing techniques and modifications for the bathroom to allow for safe bathing were discussed”
How do you make building a bird house a skilled service?
Task to facilitate pincer pinch
Requires client to follow 4 steps
Required patient to read directions
What are the essentials of the OT record?
Name and demographic info
DX = diagnosis
- Primary (medical dx) and treatment dx
* OT cannot establish medical dx, only treatment dx
Initial eval and results
- Prior condition and current condition
Treatment goals/plan
Progress notes - may be daily
Re-eval as appropriate and modify
Discharge status
- initial eval compared to current status
Summary of treatment
- pt received OT 3x week for 6wk
- pt received education….
- compare eval to current status
- where are they going? DC with HEP
Caregiver name and discharge instructions
