Intro Flashcards
What is the function of documentation?
- support intervention
- communicate with others
- measure of quality/effectiveness
- legal document
Documentation improves based on
- your knowledge
- legibility
- structure
- practice
How do federal and state laws control documentation?
State says how/what must be documented, i.e., abuse
Federal says must document BP, pain, need for medical care
How do accreditation standards control documentation?
You must teach certain standards
How do AOTA and state licensure control documentation?
AOTA gives ideas, standards of practice, “We think you should…”
ASBOT makes you document
Who controls documentation?
Federal and state laws
Accreditation standards
Company, institution
AOTA and state licensure
What do we document in?
Paper charts
Electronically
School records
The documentation follows the OT process. What is the order?
- Referral/screen
- Evaluation
- Intervention planning
- Implementation
- Outcomes/reevaluation
- Discharge
What type of language to we use when documenting?
Person first
When referring to the patient use: “the client/patient” or their name
Use gender specific pronouns
When referring to the therapist or service use: OTR, this therapist, the occupational therapist; OT, occupational therapy
What are new issues in documentation regarding technology?
Laws haven’t kept up
Can’t use personal email
Must document all calls, texts, and emails
What format should you use when contacting a patient?
SBAR
Situation (who you are, where you work)
Background (who you are calling about, BD, etc.)
Assessment (what you have found)
Recommendations (why you are calling, referral, change, etc.)
Who provides indemnity programs?
Usually provided by employers but can also be purchased independently
What are examples of indemnity programs?
Blue Cross, Tricare, United Health Care
Indemnity insurance (private pay - funded by employee, employer, or self): BCBS
Health Maintenance (HMO) or Managed Care (MCO)
Medicare: funded by federal government
Medicaid: funded by state and federal government
Cash
Premium
Cost of the policy
Up to employer on how the cost is split up
- employers pay 50% and you pay 50%, etc.
Copay
portion you pay for services despite the deductible
Deductible
amount you must pay out of pocket before insurance kicks in
HMOs and MCOs
Health Maintenance (HMO) or Managed Care (MCO)
Usually less expensive than indemnity plans
Modeled with a gatekeeper who prevents individuals from seeking “unnecessary” services or will tell you where to go to receive certain services
Works within a network and rarely allows you to go out of network
May set limit on visits, treatment, or dollar amount
Medicare
Falls under Social Security Act
- Covers those over 65
- SSI disability
- End stage Renal Disease
Medicare has 2 main parts
What are the parts of Medicare?
Part A: hospitals, SNF, Home Health, Hospice
- No charge
Part B: outpatient services, long-term nursing, adaptive equipment
- Patient pays a premium
Part C: supplemental (patient pays) usually comes from other source to pick up the difference
Part D: medication
The BBA of 1997
The Balance Budget Act
Passed to decrease the cost of Medical
Instituted a $1500 cap for OT and $1500 for PT/ST for outpatient-was repealed by the BBA of 2000.
- Now it’s at $2230.00. After that you must include a KX modifier with medical necessity
DRGs vs RUGs
Diagnosis Related Groups
resource utilization groups
- Based on resources (cost of living, availability of staff)
Medicaid
Began in 1965
Develop to provide for the poor and uninsured
Federal program, but state managed
- Feds match
- State sets up and runs it
Varies from state to state
Some states (CT, RI) don’t have it!
OT regulation agencies
NBCOT
State Licensure
Varies by state, Modalities and Georgia
ALOTA/AOTA
Others: CHT
Medical organization regulations
JCAHO: Joint Commission on Accreditation of Health Care Organizations
NCQA: National Commission for Quality Assurance
CARF: Commission on Accreditation of Rehab Facilities
Others - NBAOS: National Board of Accreditation for Orthotic Suppliers
OT scope of practice is always changing because of the forces of…
Policy
Reimbursement agencies
Accreditation organizations
Move to health and wellness
Meeting the requirements of payors, but remaining true to the practice
- Multidisciplinary teams
- Crafts to occupational performance
Role of computers
Genomics and OT
Mental health
Returning soldiers
The very very old
