OT clinical experiance 1 Flashcards
Health
Not merely absence of disease.
Well-being
holistic physical, mental and social aspects
Participation in life
through engagement in occupation
OT practice is a client-centered process that centers on enabling individuals to perform necessary life tasks into?
Meaningful occupations
Client Centered
approach to gather information
What are 5 things that are put in a occupational profile?
- Occupational history
- Interests
- Experiences
- Habits
- Patterns of daily living
OT provides interventions for people who have problems?
engaging in an Area of Occupation.
Focus on the _____ _____ ____ _____ is critical for showing the necessity for OT and to prevent any question of duplication of services.
ability to engage in occupation.
What are 6 ADL’s and IADL’S?
- Work
- Leisure
- Play
- Education
- Social participation
- Rest and sleep
What are 5 internal contexts?
- Age
- Culture
- Values
- Religion
- Developmental stage
What are 3 external context?
- Physical
- Social
- Virtual
Skills need to be transferable to the client’s own _______ they are going to.
Environment
Activity demands
Task analysis
Influence client’s performance in occupation?
The Client Factors
What are the 3 Influences a client’s meaning of life and motivation?
- Values
- Beliefs
- Spirituality
Provides a physical framework to enable all body systems to function.
Body structures
Body systems perform their duties ( neuromuscular, sensory, pain function, mental function, etc.)
Body Functions
Performance skills
Observable elements of action the have implicit functional purpose.
Emotional regulation
observe coping etc.
Give example of Motor Skills / Praxis?
Handling objects, mobility, balance, energy level, & interactions
Cognitive & Sensory/ Perceptual Processing
Organizing time & task components
Communication/ Social interaction
Physical and verbal aspects of communication & relating to others.
Specify in documentation what activity demands are problematic and what intervention, ______ _______ or ________ are needed for occupational performance.
- Grading methods
2. Adaptions
3 Methods in which to attain desired client outcomes?
- Managing chronic conditions
- Enabling occupational participation
- Improving quality of life
7 Types of occupational interventions
- Occupations
- Activities
- Preparatory methods ( done to the client)
- Preparatory tasks ( done by the client)
- Group interventions
- Advocacy and self – advocacy
- Education and training
Documentation concerning intervention should contain what 4 things?
- Delineate the specific methods used
- The client’s response to intervention
- Progress made toward goals
- Any changes to the intervention plan
Initial Evaluation
OT directs OTA contributes
Initial Evaluation
OT directs OTA contributes
Contact Notes
OTA completes OT signs
Progress Notes
OTA completes OT signs
Reevaluation Notes
OT directs
Transitional Notes
OT completes
Discharge or Discontinuation Notes
OT directs OTA contributes
Medical records or Health Records is a Legal document contain what 2 things?
- Provides history of client’s past and present health
2. Substantiates care
Substantiates care ( 4 things)
- Advance directives
- Vital statistics
- Course of treatment
- Related correspondence
Primary purpose of health records?
Exchange of information among health care providers.
HIPPA
Health Insurance Portability and Accountability Act
FERPA
Family Educational Right and Privacy Act
HITECH
Health Information Technology for Economic and Clinical Health Act
ACA
Affordable Care Act
FDASIA
Food and Drug Administration Safety and Innovation Act
IMPACT
Improved Medical Post-Acute Care Transformation Act
IDEA
Individuals with Disabilities Education Act
Advantages electronic health records (3 things)
- Legible and organized
- Centralizes chart management
- includes prompts and templates
Disadvantages electronic health records (3 things)
- Significant cost and time to implement
- Sift through various menus
- Point of service may take away client.
Evaluation (2 things)
- Occupational profile
2. Analysis of occupational performance
Intervention (3 things)
- Intervention plan
- Intervention implementation
- Intervention review
Outcomes ( 1 thing)
Re-evaluations
Skilled services
those services that require decision making and highly complex competencies and have well-defined knowledge base of human functioning and occupational performance.
Non-skilled services
those that are routine or maintenance type of therapy, both could be carried out by nonprofessional personnel or caregivers.
Rehabilitation Aides can not (3 things)
- provide skilled therapy
- Guide or direct services
- Provide professional judgement
Rehabilitation Aides can (4 things)
- transport client to therapy.
- Clerical tasks
- Routine maintaince
- Unskilled departmental tasks
Safety concerns
The ability to perform a task must include the ability to do it safely.
Prevention of Secondary Complications
OT if it can be shown that the client has a high risk of developing complications.
Managed Care
guides OT services documentation and reimbursement guidelines
PPS- Prospective Payment System
Predetermined per-diem rate according to diagnosis and level of care needed.
CPT- Current Procedural Terminology
These are codes we use for billing specific treatments
Timed services
Codes requiring constant attention 1:1
Untimed services
evaluations
Group rules
4 client in one hour = 15 min each
