Midterm B Unit 6 Flashcards
Client information
record the patient’s name, date of birth, sex, health status, medical history, medical/educational/developmental diagnosis, precautions, and contraindications.
Every element of this information is important to include in your documentation: It makes a difference in terms of reimbursement and demonstrating whether your client is receiving a low-, medium-, or high-complexity evaluation. Identifying the client appropriately in the medical records is essential to keeping fidelity across medical records and making the electronic health record a source of information and education that can be used across settings.
Recall the information about reimbursement and the merit-based incentive payment system for outpatient therapy:
One of the requirements for reimbursement is the quality use of electronic medical records to communicate with other stakeholders. Ensuring consistent and appropriate documentation even at the most basic level of client information is important. Making sure to document the specific medical history, health status, primary and secondary diagnosis, precautions, and contraindications also helps you to explain why your evaluation should be reimbursed at a low-, medium-, or high-complexity rate based on the new evaluation CPT codes. This is not the section to rush through or omit information from. Sometimes you will need to go to the person’s medical record, MDS coordinator, or caregiver, or contact previous or current medical providers for information.
Referral information
In this section you want to make sure that you include the date and source of the referral, as well as the services that are requested, the reason for the referral, the funding source, and the anticipated length of stay. Sometimes this information will be included in the section where client information is also found.
regard to the referral information
be sure that you include the functional reasons that the client has been referred for services. Saying that the client was referred for services for evaluation and treatment by the physician does not give the reader information about the functional reasons for OT to be involved in the client’s case. Information about the referral may come from your screening process, family members, the client, or documentation from previous medical visits.
Occupational profile
more subjective section of your evaluation, where you report the reasons for occupational therapy services and the areas of occupational functioning that the client is succeeding in or is being challenged in.
should demonstrate a clear functional need for skilled occupational therapy services, a previous history that demonstrates a significant difference between prior level of functioning and current level of functioning, and a willingness on the client’s part to be engaged in the therapy process. This section requires clinical reasoning and critical thinking to ensure that you are including only relevant information while being detailed enough to indicate the need for therapy services.
Environmental Factors and Personal Factors
related to occupational performance and any history that’s relevant to the client’s diagnosis and current performance. This section also describes the client’s motivation and goals for participating in therapy.
Assessments used and results
the objective in nature and includes the types of assessments used and results reported from the evaluation process. Observations, standardized and nonstandardized assessments, and interviews should all be included in the section. Here you are stating the facts. Include which specific assessments were performed and what the results were, with minimal interpretation. This can sometimes be achieved using a chart-like format. It is important to report the exact results of the assessments as you completed them and describe any alterations in assessment performance that should be noted by future clinicians involved in the client’s care.
Example of assessments used and results
evaluations performed during separate time periods due to a client’s fatigue, or did you have to skip a section of an assessment because the client was unable to complete the task? This type of information makes documentation more reliable and ensures that reevaluations and discharges will accurately reflect a client’s progress and performance over time.
Analysis of occupational performance
let your occupational therapy knowledge and clinical reasoning shine. The analysis section provides the description and evaluation of the performance skills, performance patterns, context and environment, activity demands, and outcomes that you determined based on your interpretation of standardized and nonstandardized assessments. This section requires you to take the data from the evaluation process and give it meaning. It is not enough to restate the results you found. Those results need to be connected to functional performance and occupational engagement. For example, restating that somebody scored 16 on the Montreal Cognitive Assessment (MoCA) is no different than listing scores in the assessments used and results in section. In this section, you need to expand on the data and explain which areas of the assessment the client struggled in—which could relate to performance skills or client factors. For example, you might report that “the client demonstrated difficulties in performing visuospatial activities, especially the clock-drawing task.” The details provided in this section build your justification for providing skilled services.
Summary and analysis
includes an interpretation of the entire evaluation process: It incorporates the occupational profile information along with the referral concern and the assessment data to demonstrate a need for skilled services. This is a summary of sorts that should clearly indicate functional-based problem statements that align with the client’s prior level of functioning, the current level of functioning, referral for skilled services, diagnosis, client-stated goals, and assessment results.
Recommendations
information about the appropriateness of occupational therapy services, the length of occupational therapy services recommended, the types of services that may be provided with an OT, and a referral to other practitioners who should be involved in the client’s care. This is a great section for us to demonstrate our knowledge of the interdisciplinary care team and participate in care coordination and care management of the client.
