Intro to Documentation Flashcards
What is a theory?
A statement that defines and explains the relationship between the concepts of a given phenomenon, which can help predict behavior and events.
What is a model?
A model is a framework with unique, profession-specific content that is supported by a foundational theory, which may or may not originate from within the profession.
What is a frame of reference?
An FOR is a system of interrelated concepts, which are consistent with a profession’s theories and models, and may be used to address a specific and limited domain of practice through a particular approach.
PEOP model
Focuses on what individuals do in their daily lives, what motivates them, and how their personal characteristics interact with occupations that are undertaken to influence occupational performance.
Motivation is divided into intrinsic theories and cognitive theories of motivation.
Self-efficacy describes an individual who sees themselves as competent.
Occupational performance = “doing of occupation”
PEO Model
Focuses on occupational performance and its link to people, occupation, roles, the environment, work, and play as a dynamic interwoven process.
With this model, the focus of OT eval/intervention is to elicit change and facilitate improved occupational performance.
Occupational Adaptational Model
Encourages the therapist to assist the client to identify occupations to which they are interested in returning.
Based equally on the individual, the environment, and the client’s interactions, this model emphasizes the use of meaningful occupations to allow the client to experience adaptation—which leads to mastery.
MOHO
Emphasizes how individuals continuously engage in a feedback loop (input, throughput, output).
This cycle influences occupational behavior.
Info is processed with subsystems (volition, habituation, and performance).
Ecology of Human Performance Model
Based on premise of how human behavior and task performance are affected by the interaction between a person and the context (the ecology).
The OT intervention process is designed to improve the client’s performance by changing variables such as the person, the context, the task, or the transaction between them.
These variables (person, context, task performance) have an affect on, and are affected by, human performance.
Intervention approaches
Create
Restore
Maintain
Modify
Prevent
Create and restore
These involve changing the individual’s environment including physical, social, and institutional issues as well as technological strategies (devices/aids)
Maintain
Focuses on the person and on the approaches to recovery/adaptation of neurological, sensory, and motor issues
Modify and prevent
Involve the delivery of services and the strategies the OT will use to facilitate changing attitudes, policies and laws that affect the rehabilitation process.
Grading
Viewing an activity on a continuum from simple to complex; it is more of a remedial approach but can also be used as an adaptive/compensatory approach. As a client gains skills in a particular task, the expectation will increase.
Task analysis
Task analysis is completed prior to initiation of intervention; the therapist has a clear understanding of what components of a task can be graded as improvement is noted.
Chaining
Backward chaining – when the OTP begins the task and then asks the client to complete the task; allows sense of accomplishment when the task is finished
Forward chaining – when the client begins the task and once unable to complete the task the OTP steps in.
Both methods offer grading, forward chaining can often lead to a feeling of failure. For this reason, backward chaining is preferred. Example – tying shoes.
Carryover
In OT, carryover means that instructions given, or tasks learned will be repeated at later sessions of therapy or by the client in a setting like the original setting of instruction.
Toileting with adaptive equipment at hospital vs. regular at home
Generalization
Generalization is the ability to complete carryover in a variety of settings. These are the skills and performance of applying specific concepts to a variety of related solutions.
Toileting in public after toileting with adaptive equipment at hospital
When suggesting adaptive equipment/durable medical equipment to a client, consider the following:
Prospective use of the equipment
Desire of the client
Cost of the equipment
Functionality
Reflective practice
Law (2002) emphasizes the need for OTPs using evidence-based practice to become reflective practitioners. Reflective practice involves use of clinical reasoning skills for decision making. Law uses the E Model as a decision-making tool and means of reflection.
Expectations – shaped by client’s needs and therapists knowledge of theory in order to formulate assumptions
Environment – influences thoughts, beliefs, and actions.
Experience – may be formal or informal.
Ethics – guided by governing bodies and personal philosophy
Evidence – improves with access to and emphasis on the process
Documentation in intervention
Documentation in OT intervention involves the practitioner’s contribution to the client’s record.
Documentation is a method of communication of services provided for the health care team as well as third-party payers.
It is a vital part of the intervention process.
Purpose of documentation
Main resons:
1. Facilitation of effective intervention
2. Justification of reimbursement
3. Documentation as a legal document
4. A communication tool for the health care team, client, and family
Other reasons:
5. Accountability for actual intervention and time spent w/client
6. Method of recording results of evaluation, intervention, and re-evaluation
7. A legal requirement
8. Method for recording & measuring progress, status of client’s condition, and response to intervention
9. Requirement to validate reimbursement
10. An ethical responsibility of health care professionals
11. To document baseline of function
12. Continuity of care
13. Communication tool for any potential audience
14. A permanent record of occurrences
15. Allows for observable, measurable changes in progress
Documentation requires
Appropriate terminology
Professionalism
Guidelines for documentation
Be accurate and collect accurate information
Be complete
Use proper spelling and grammar
Be clear and concise
Avoid jargon; unacceptable abbreviations should be avoided
Avoid arrows, hyphens, etc.
Be careful with buzz words and “red flag” words
Focus on function, underlying cause, progress, and safety
State expectations for progress, slow, or lack progress
Summarize need for skilled services
When should you document?
Upon admit
Daily
Weekly
Monthly formal re-evaluation
When changes occur; with progress or lack thereof
Medical changes/complications; client placed on “hold”
When physician needs information
Discharge summary – include barriers to progress/effectiveness of intervention
Basics for documentation
Think about what you will write before doing it
Sign and date
Check for grammatical/spelling errors
Use blue/black - no erasing!
Errors are neatly crossed out with a single line and “error, initials, and date” is written next to the error
Limit the use of abbreviations –only use accepted ones
Write legibly, including signature (or print name underneath/beside)
Components of documentation
Client identification
Date and type of contact
Type of documentation
Signature/countersignature
Terminology
Corrections
Confidentiality and handling of records
Documentation process
- Screening – Chart review and actual screen; not a billable service; not hands on, look but don’t touch
- Evaluation – Use of assessment tools
- Planning Intervention – Setting of collaborative goals, select approaches, methods, tools, and strategies
- Service delivery – how intervention be delivered and implemented
- Monitoring progress – re-evaluate and adapt plan
- Discharge therapy – maintenance program and follow-up plans
Specific types of documentation
Screening note
Contact note
- Evaluation report
- Intervention/progress note
- Re-evaluation report/note
- Discharge note/discontinuation summary
- M.D. report
SOAP note
- S = Subjective
- O = Objective
- A = Assessment
- P = Plan
SOAP note
S = Subjective
- patient’s subjective response to interventions
- patient’s report of changes in participation or activity limitations
O = Objective
- status update: indicate any objective, measurable changes in patient’s status
- intervention: provide summary of interventions that were performed
- measurable, quantitative, and observable actions during the session
A = Assessment
- indicate progress being make toward patient’s goals
- discuss factors that modify frequency or intensity of intervention and progression toward anticipated foals
- justification of continuation of therapy
- modify or state new goals if necessary
P = Plan
- specific intervention plan for upcoming sessions, with revision of original plan of care if needed
- report what patient will be doing between session (home program, other interventions/tests)
COAST notes
C = client
- identify the client
O = Occupation
- identify the functional task being addressed
A = Assistance Level
- what level and type of assistance is needed for the client to perform the task
S = Specific Condition
- what conditions are necessary for the client to achieve the tasks
T = Time
- by when the goal is expected to be achieved
