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.
