Pedretti Ch. 8 - Documentation of OT Services Flashcards
AOTA purposes of documentation
- Articulate rationale for provision of OT and how it relates to client outcome
- Reflect therapist clinical reasoning and professional judgement
- Communicate info on client from OT perspective
- Create chronological record of client status, OT services provided, and client outcomes
Best Practice
- Complete documentation as soon as the therapy session as possible (less chance of forgetting), can use notebook
- Altering, substituting, deleting information from the client record should never take place
- How to correct an error: draw single line through it, and date and initial the entry
- Documentation should include terminology in the OTPF-2
- Emphasize OT supporting function and performance in daily life activities and how those factors influence performance during eval and intervention process
- Use “client” for someone receiving services
Initial Evaluation
Short-term goals are made here
Process of obtaining and interpreting data necessary for understanding the individual, system or situation
Account for client’s current and past status to justify the need for OT services
Use assessments during evals using clinical judgement to choose which assessment to use
Evaluation report should include:
Client information, referral information, occupational profile, assessments, analysis of occupational performance, summary and analysis, recommendation
Intervention plan
Problem statements should include a description of the underlying factor and its impact on the related area of occupation
- Factor: performance skill or pattern, client factor, contextual or environmental limitation, activity demand
Goals must be measurable and objective and include a time frame and directly related to the client’s ability to engage in desired occupations
Overarching goals in OT intervention is “engagement in occupation to support participation”
Short and Long term goals (discharge goal)
Establish Goals, then Skilled interventions → make a plan
Progress reports should include:
The client outcome
Skilled interventions by OT
- Description of the type and complexity of the skilled intervention and reflect therapeutic rationale underlying the task
Progress that resulted from the OT intervention
Reimbursement for clinical services provided is dependent on __
Reimbursement for clinical services provided is dependent on documentation that demonstrates the clinical reasoning that underlies the intervention
SOAP Notes
For charting in the POMR (problem-oriented medical record) focus on problem instead of the dx
Subjective
- Information reported by client/caregivers, subjective response
- Only contain relevant information that will support the therapist’s decision regarding which assessments should be used and which goals are appropriate for this client
Objective
- Assessment results, tests, measurements performed, objective observations
- Data is measurable, quantifiable, observable (factual info only)
- Emphasis on results of the intervention not on intervention itself
Assessment
- Therapist uses S, and O sections to establish OT program
- Impairments and functional deficits analyzed to establish most appropriate therapy program
- Summarize relevant assessment findings, synthesize information, analyze its impact on occupational performance, and utilize it to formulate the intervention plan
- Requires keen observation, clinical reasoning, and judgement skills, and an ability to identify relevant factors that inhibit or facilitate performance
- SHOULD end with a statement justifying the need for continued therapy services
Plan
- Intervention plan
- Short term goals -> established and revised once met and modifications to therapy frequencies
Narrative Notes
Narrative note is one format to document daily client performance
Narrative notes may be found in a designated area in the medical chart, or all clinicians involved may write on a single note
Date, beginning/end times of therapy, therapist signature must be included
Narrative format may also be used to convey info to other team members
Organizing narrative notes
Organize narrative notes by categorizing the info into subsections:
Problem: clearly identified impairment and functional impact
Program: intervention or intervention modality
Results/progress: results are documented in measurable, objective terminology
Plan: the plan for future intervention & the need (and rationale) to modify goals
Descriptive Notes
Short, descriptive notes that relay important info about client
Notes should be as objective as possible, but sometimes may include subjective info
Negative comments, info not related to the client’s intervention program should be avoided
Unobserved behaviors in the client record should be recorded w/ clear explanations as to who provided the info to the therapist
Progress Checklists or Flow Sheets
Can be used to document daily performance efficiently
- Often used in settings with high productivity demands and lack of reimbursement for documentation
Flow sheets typically use a table/graph format to record measurements at regular intervals. Typically after each session
Flow sheet advantages
Improved clarity and organization of data
Reduction in quantity of data needed to be recorded after each session
Improved focus on interventions specific to the client’s goals
Clearly ID’s the client’s functional status and progress
Flow Sheet Disadvantages
Space is often not sufficient to:
- include subjective statements to explain client performance
- document the therapist’s interpretation of the objective info
- describe the client’s response to the intervention
progress checklist
Provides a description of what the client did on a level of assistance or objective measurements, but no info on the quality of the task accomplished or the modifications made for successful completion of the task
- the missing info can be included in a narrative format on a separate note sheet
- info from the daily checklist/flow sheet is used to write a weekly progress note
RUMBA aka RHUMBA
RUMBA test can organize the therapist’s though process for effective documentation
Is the information Relevant?
- the outcome must be relevant, the goal/outcome must relate to something
How long will it take?
- When will the goal/outcome be met
Is the info Understandable?
- Everyone must understand what the document means
Is the info Measurable?
- There must be a way to know when the goal is met
Is the info Behavioral (describes behaviors)?
- Goal/outcome must be something seen or heard
Is the outcome Achievable (realistic)?
- Goal/outcome must be do-able
Therapist can review the document to determine if these questions have been answered, while keeping target audience in mind
SMART
Achieving this goal will make as Significant difference in the client’s life
There is a clear, Measurable target to aim for
- You will know when the client reaches the goal
It is reasonable that the client can Achieve this goal in the time allotted
Long and short term goals Relate to each other
- The goal has clear connections to the client’s occupational needs
The goal is Time-limited: short and long term goals have a designated chronological end
Discharge Reports
Written at the conclusion of therapy program
Compares functional performance from initial eval to discharge to document progress
- Emphasis on progress made in engaging in occupations
Summary of skilled interventions provided to client is included
Discharge recommendations (home programs, therapy follow-up, referrals etc.)
Summary should demonstrate the efficacy of OT, and are often used to obtain info for outcome studies.
Clients are discharged when they:
- Achieved est. goals
- Received max benefit from OT
- Have refused to participate further therapy
- Exceeded reimbursement allowances
Documentation Format Types
Documentation can be paper based or electronic
Electronic Medical Record (EMR) is becoming more common, esp. in hospital settings
Increase of regulations, complex reimbursement structures, and pressure for increased productivity make electronic documents more effective
Since health care providers can enter info on a common database, the team can quickly access info about the patient
Electronic notes disadvantages:
Need access to an available computer
- Allow time to find a computer that is not in use. This is an issue if notes need to be entered in chronological order, as the therapist may not be able to wait until the next day to enter info
Some forms are restrictive in what you can enter
Often long time lapses between computer updates
Content of the forms used to document are often determined by ____
Content of the forms used to document are often determined by the requirements of the 3rd party payer reimbursing the service and the needs of the practice setting
OT documents must:
- Contain info to justify the need for OT
- Demonstrate the provision of skilled interventions
- Show client progress toward identified goals
Primary reimbursement systems for OT in phys-dis settings
The primary reimbursement systems for OT in phys-dis settings are: Medicare, Medicaid, various Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs)
Medicare
A national insurance program with set national standards for documentation (i.e. what info must be included to justify the need for OT services)
Medicare is a major payer source for the geriatric physical disability setting
Medicare Benefit Policy Manual
The Medicare Benefit Policy Manual describes key phrases that medical reviews are looking for when reviewing claims
Intermediaries will reimburse OT services only if
Intermediaries will reimburse OT services only if all Medicare guidelines have been met. Medicare requires that specific information of therapy process is clearly documented for services to be reimbursed
Medicare 700 form
Medicare has a specific form for outpatient evals = the Medicare 700 form aka “Plan of Treatment for Outpatient Rehabilitation”
- Its exclusive use is no longer required
- Documentation on the initial eval must demonstrate that it is reasonable for the therapist to complete the eval to determine if restorative services are appropriate
- Must include the client’s prior level of function and the change in function prior to OT referral
- This info serves as basis for short/long term goals
- A recent change in function (a decline or improvement) is required to justify therapy
- Goals cannot address issues that do not have supporting baseline data in the Assessment section
- The plan of treatment includes functional, measurable goals based on assessments results
- Plan of treatment – the skilled intervention the OT provides
The 700 form also functions as the end of the month progress report and/or the discharge form
Maintaining confidentiality in documentation is the responsibility of ____
Maintaining confidentiality in documentation is the responsibility of the OT
Principle 3E of the AOTA code of Ethics
Principle 3E of the AOTA code of Ethics addresses privacy and confidentiality in all forms of communication, including documentation
Guidelines to the Code of Ethics
Information that is confidential must remain confidential
Info cannot be shared verbally, electronically, or in writing w/o consent. Info must be shared on a need-to-know basis with those having primary responsibilities for decision making
HIPAA
outlines the expectations of health care professionals in issues of confidentiality
Protected health information (PHI)
Health Insurance Portability and Accountability Act
Individually identifiable health information = protected health information (PHI) also protected under HIPPA
PHI: health info that relates to a past, present, or future physical/mental health condition
Gives patients the right to access their medical records
Safeguards must not be adhered to for compliance with HIPAA
OT is responsible for to protect confidential info from unauthorized access, use, or disclosure including
Any PHI should not be disposed in the trash, but shredded. Medical records can not be unattended in public view
Written, verbal, or electronic info cannot be shared with family unless written consent has been provided by patient
Log-in codes cannot be shared by staff
