Pediatric Documentation & Reimbursement

Question 1

Why must we document?

Answer 1

develop occupational history
learn client values + needs
justify service/reason for OT
help decide + adjust intervention
demonstrate skilled OT
past achieved outcomes

Question 2

What are the guiding resources for documentation?

Answer 2

OT Standards of Practice
State practice acts
OT Code of Ethics
State + federal requirements
State + federal laws

Question 3

What is the process for outpatient services?

Answer 3

Referral
Evaluation
Plan of care
Treatment notes
SOAP notes
Progress notes
Discharge

Question 4

What should be checked upon referral?

Answer 4

insurance coverage:
# of visits
type of OT services
financial coverage
diagnoses
MD order

Question 5

What should be included in an evaluation?

Answer 5

client history
occupational profile
physical
level of function
OT needs
potential
recommendations
client name + DOB
date + OT signature

Question 6

What is included in the plan of care?

Answer 6

diagnosis, time, goal + treatment

Question 7

What is included in treatment notes?

Answer 7

date
matched services to code
response to treatment
progress assessment
challenges to progress
demonstration of skilled OT
changes in plan of care
sign, date, credentials

Question 8

What are some tips for writing SOAP notes?

Answer 8

subjective -> client’s POV of last visit’s
effect
analyze/assess -> what improved?
plan -> thorough for next session

Question 9

What is included in progress notes?

Answer 9

medical necessity
progress, but why still needed
start date + timeframe
baseline comparison
updated plan of care (goal achieved,
new goal, why not met?)
updates to recommendations,
consults, referrals, HEP, etc.
sign, date + title

Question 10

What is included in discharge?

Answer 10

reason (goal achieved, plateau,
unable to participate,
noncompliance)
client info + diagnosis
summary (# of visits, intervention,
progress, goals)
future recommendations (ie.
referrals)