PD text Chapter 5 (quiz 1) Flashcards
What are the purposes of documentation for occupational therapy?
- Articulate the rationale for provision of OT services.
- Reflect the OT practitioners clinical reasoning.
- Communicate information about the client from the OT perspective.
- Create a chronological record of client status, OT services provided to the client, and the client outcomes.
What are the OTA responsibility to document?
- for preparing certain reports as delegated by the occupational therapist.
- Documentation of the clients response to the intervention.
- communications between the OTA and the client during intervention.
What is a SOAP note?
Are a format that has been adapted by many professionals in medical and allied health fields.
What does SOAP stand for?
S= Subjective O= Objective A= Assessment P= Plan
What for the four main components of Functional outcomes?
- Performance
- Criteria
- Condition
- Time Frame
What is a EHR
Electronic Health Record
What is a EMR
Electronic Medical Record
Documentation is made up of what 4 processes?
- Begins immediately on the receipt of the initial referral
- Should record the clarification of the referral
- initial evaluation results
- ongoing daily and/or weekly progress notes.
What is the Occupational Therapy Code of Ethics and Ethics Standards?
Discusses the idea of truth, which is one of the seven core concepts of the OT.
What are some Fundamental Elements of documentation?
- Clients full name and case number on each page of documentation.
- Date and type of OT contact.
- Identification of type of documentation and department name.
- Ot practitioner’s signature, with a min of first name or initial, last name and professional designation.
- Signature of the recorder directly at the end of the note.
- Facility approved abbreviations.
what is Subjective?
What has been said subjectively by the client or what has been reported by significant others.
What is Objective?
Observable and measurable data derived from evaluation and treatment results.
What is Assessment?
the opinion, interpretation, or assessment of the results of the client’s functional performance and anticipated outcomes including a problem list and long and short term goals.
What is Plan?
The treatment plan including the frequency and duration of treatment.
Independent abbreviation
Ind.
Independent
Client requires no assistance or cueing in any situation and is trusted in all situations 100% of the time to do the task safely.
Supervision abbreviation
Sup.
Supervision
caregiver is not required to provide any hands on guarding but may need to give verbal cues for safety.
Contact guard/standby abbreviation
Con.GD/Stby
Contact guard/standby
Caregiver must provide hands-on contact guard to be within arm’s length for clients safety.
Minimum assistance abbreviation
Min.
Minimum assistance
caregiver provides 25% physical and or cueing assistance.
Moderate assistance abbreviation
Mod.
Moderate assistance
caregiver assists client with 50% of the task. assistance can be physical and/or cueing.
Maximum assistance abbreviation
Max.
Maximum assistance
Caregiver assists client with 75% of the task. Assistance can be physical and or cueing.
Dependent abbreviation
Dep.
Dependent
Client is unable to assist in any part of the task. Caregiver performs 100% of the task for client physically and/or cognitively.
Modified Independance abbreviation
mod. I
Adaptive Equipment abbreviation
AE
