laura midterm Flashcards
Why do we document
- To show what has happened to the client
- To show our high level of clinical reasoning
- Demonstrate the effectiveness of OT for 3rd party payers
- What has happened during intervention session
Professional Communication Skills
The message should be conveyed professionally using appropriate tone ( most important), active voice ( putting the client first then he action) and non discriminatory language.
Whats a model?
A model is a way of organizing information, to guide your thinking.
Whats a F.O.R
Its a bridge between theory and practice. Its more specific and guides treatment. It tells the OT how to use the information in practice.
Top down approach
Its focus is on the clients performance followed by their skills, and activity demands. There main goal is on engagement in meaningful occupations.
Bottom up approach
Emphasizes on the strengths and areas that need improvement. They focus on improving skills first, and then work on performance.
Referrals
A suggestion made by somebody that suggests that a patient receive OT services.
Whats an OTs role in dealing with referrals?
An OT can accept and respond to a referral
Screening
A brief assessment to determine if a comprehensive evaluation is indicated.
What can a COTA do in a screening
A cora can contribute if competent and under the supervision of a OT.
Evaluation reports
Demonstrates the need of OT services. They are done to describe a its level of performance, predict future functions and outcomes.
Whats an OTs and COTAs role in evaluation reports?
An OT is responsible for completing the eval report, while the cota can contribute to the process.
Intervention plan
Where the OT articulates the expected outcomes and how they will be achieved. It is based on the results from the veal report. The wants and needs of the client also should be put into consideration.
Whats an OTs role in an intervention plan?
an OT is responsible for developing and documenting while a cota can contribute to the process.
Evidence based Practice
Shows that your plan of intervention is supported by research, and that you are update with the current knowledge and findings.
P.I.C.O.
P: patient population
I: intervention
C: comparison
O: Outcome
Abstract
summary of the article
Introduction
why research was done
methodology
how the research was done
discussion
what the results mean
conclusion
what they learned
Individualized Education Plan
I.E.P: A guided document for special education and related services for children w/ special needs. Designed for 1 student and looks at their level of education.
Individualized Family Service Plan
I.F.S.P: A written document that specifies the unique strengths and needs of the child and their family. The steps that will be taken to help the child achieve the outcomes that are desired.
Mentoring
A partnership that has it primary focus on a career or personal growth. They guide and support.
Restorative goals
What the pt can’t engage in anymore
Habilitative goals
promoting a new occupation or skill
maintenance goals
maintain current abilities
preventative goals
preventing someone who is at rick of developing performance problems
health promotion goals
enrichment or enhancement of occupational performance
modification goals
changing context or activity demands as opposed to chaining the skills of the client. ( grading)
ABCDE
A: audience B: behavior C: condition D: degree E: expected time
