Module 2: Documentation in OT Practice Flashcards
What are the two types of records?
- Clinical Records
- Administrative/Departmental Records
These contain information that relate to patient care such as OT notes, referral notes, assessment notes, etc.
Clinical Records
These are records created for administrative purposes such as Statistical Records, Personal Management Records, Equipment and Supply Records, and Financial Records.
Administrative or Departmental Records
Who are the audiences for OT documentation?
- Medical professionals
- Educators
- Accreditation agencies
- Payers
- Client & Caregiver
The documents’ goals and purpose are clearly stated.
“Function & Purpose” in documentation
The documents’ are capable of being understood and transmitted.
Communicability in documentation
Documents achieve consistency for comparison purposes.
Standardization in documentation
The application of physical appearance technicalities in documents.
“Form Development & Design” in documentation
Confidentiality is practiced and clinic owns all records.
“Ownership and Retention” in documentation
The reporting and interpretation of clients’ responses on assessments and interventions in a medical record.
Clinical documentation
Essential features of clinical documentation (6)
- Date of completion of report
- Full signature & credentials
- Type of document
- Client name & case number on each page
- Acceptable abbreviations
- Acceptable terminology
What are the documents under the Initiation stage of OT?
- Screening document
- Evaluation document
Taken prior to an evaluation
A short note usually written summarizing the conversation and the results
Screening
Reports written by OT to document the start of intervention
Containts factual data collected during the process and its interpretation
Evaluation
Contents of evaluation reports (8)
- Identifying & background information
- Referral information
- Evaluation procedures / tests used
- Occupational profile
- Findings & results
- Interpretation of results
- Plan of intervention
- OT’s signatures & credentials
It contains a prioritized problem list, the goals related to the problem, and the desired potential functions and improvements
Intervention Plan Document
Types of goals
- Long-term goals
- Short-term goals
Change in occupational limitations and change in participation restriction occur
Occurs prior to the termination of intervention wherein desired functional outcomes are achieved
Long-term goals
Component subskills which are to be achieved over short time frames
Successively lead to the attainment of the LTG
Short-term goals
In writing a goal statement, the _____ structure is mostly used in the Philippines:
ABCD (Audience - Behavior - Conditions - Duratio)
LTG’s and STG’s should be written in the _____ structure
SMART (Specific - Measurable - Attainable - Realistic - Timebound)
In SMART, it refers to tangible outcomes
What does the client want to do?
Specific
In SMART, it gives concrete data on the degree of client’s performance
It is essential for reimbursement and tracking progress
Measurable
In SMART, client must want to reach their goals because they are realistic
Realistic
In SMART, it is the duration for how long goals are meant to be done
Time-bound
What is the CARE format
Clarity - Accuracy - Relevance - Exceptions
Contains the procedures to be used, clients’ response to activities, goal modifications when indicated for, attendance or absence from treatment plan, and more
Intervention Implementation Documentation
What are the documents under Documentation for Continuing OT Services?
- Progress notes
- Clinical/OT notes
These periodically document care coordination and interventions.
Updates progress towards functional and treatment plan goals.
Describes clients’ reactions
Progress notes
Documents individual OT sessions
Done briefly, usually every day or after every session
OT/Clinical notes
In writing the Progress and OT notes, the _____ format is used
SOAP (Subjective - Objective - Assessment - Plan)
In SOAP format, it pertains to the client’s own experiences and the information reported by their families and close peers
Subjective
In SOAP format, it pertains to the clinician’s informed observations, measurements, and data obtained through assessments
Objective
In SOAP format, it is the therapist’s interpretation and clinical reasoning based on the gathered data, analysis of client’s status and goals.
Assessment
In SOAP format, it is the therapist’s specific steps of intervention to resolve identified problems and meet goals.
Plan
What is the BIRP format?
Behavior - Intervention - Response - Plan
What is the RUMBA format?
Relevant - Understandable - Measurable - Behavioral - Achievable
What is the POMR format and its 2 subformats?
Problem Oriented Medical Record
- SOAP (Subjective - Objective - Assessment - Plan)
- RUMBA (Relevant - Understandable - Measurable - Behavioral - Achievable)
What are the documents under Discontinuing OT services?
- Endorsement notes
- Discharge notes
Documents client’s basic information, problems, and improvement for treatment continuation.
Made for a client’s new OT if they transfer.
Endorsement notes
What do Endorsement Notes contain? (6)
- Client’s basic information
- Referral services requested
- Problems list
- Activities given during sessions
- Improvements and progress made
- Recommendations
Used as a summary of the course of the whole therapy and any recommendations
Written at the end of the therapy
Discharge Notes
What do Discharge notes contain?
- Therapy process
- Goal attainment
- Functional outcomes
- Follow-up recommendations
- Home instruction program
- OT signature & credentials
- Date
The therapeutic problem-solving method used by practitioners to help clients improve occupational performance
Theory-based and data-driven
Occupational therapy
6 Major Components of Occupational Therapy
- Theory
- Evaluation
- Problem Definition
- Intervention Planning
- Intervention Implementation
- Re-evaluation
A component of Occupational Therapy wherein practitioners systematically collect & organize data about occupational performace
Evaluation
A component of Occupational Therapy wherein data is synethesized, forming a profile of the client’s abilities and disabilities to be delienated.
Problem Definition
A component of Occupational Therapy wherein specific occupational therapy strategies & modalities to eliminate problems are proposed.
Intervention Planning
A component of Occupational Therapy wherein intervention plan is operationalized and actions are initiated to achieve outcomes.
Intervention Implementation
These are established to mark the endpoints of therapy and serve as markers of intervention plan’s effectiveness.
Outcomes
A component of Occupational Therapy that involves the recollection of data gathered during Evaluation stage to see if activities and interventions relay changes.
Re-Evaluation
