Lecture 2 Flashcards
Overarching idea or belief FOR: How we put it into practice
Theory
Documentation will focus on the function.
Top down
Documentation will focus on the performance skills. OT uses this way more often.
Bottom up
Focus on job performance
Industrial rehab
focus on ADL and level of independence
Inpatient rehab
focus on daily function, interactions with others, behaviors
Psych
Focus on safety and personal adl
Home care
source oriented medical record: Each discipline has a section in the records
SORM
Problem oriented medical record: each problem is given a number, usually developed as a team.
PORM
traditional method of documenting in OT
Subjective: what the pt said, or what you subjectively saw
Objective: Facts, what you did with the client and the factual performance.
Assessment: What you as a professional think about the situation, or your interpretation of what is going on
Plan: what you are going to do next, your expectations or goals for the client.
SOAP notes
individual treatment plan
ITP
Individual education plan
IEP
Functional independence measure
FIM
a service that requires specialized education or skills to perform can not be performed by an untrained individual. OT, PT, SLP, COTA, PTA
Skilled service
only accept skilled services for reimbursement
Medicare and Blue
