Pedretti Ch. 8 - Documentation of OT Services

Question 1

AOTA purposes of documentation

Answer 1

• 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

Question 2

Best Practice

Answer 2

• 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

Question 3

Initial Evaluation

Answer 3

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

Question 4

Intervention plan

Answer 4

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

Question 5

Progress reports should include:

Answer 5

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

Question 6

Reimbursement for clinical services provided is dependent on __

Answer 6

Reimbursement for clinical services provided is dependent on documentation that demonstrates the clinical reasoning that underlies the intervention

Question 7

SOAP Notes

Answer 7

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

Question 8

Narrative Notes

Answer 8

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

Question 9

Organizing narrative notes

Answer 9

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

Question 10

Descriptive Notes

Answer 10

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

Question 11

Progress Checklists or Flow Sheets

Answer 11

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

Question 12

Flow sheet advantages

Answer 12

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

Question 13

Flow Sheet Disadvantages

Answer 13

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

Question 14

RUMBA aka RHUMBA

Answer 14

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

Question 15

SMART

Answer 15

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

Question 16

Discharge Reports

Answer 16

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.

Question 17

Clients are discharged when they:

Answer 17

• Achieved est. goals
• Received max benefit from OT
• Have refused to participate further therapy
• Exceeded reimbursement allowances

Question 18

Documentation Format Types

Answer 18

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

Question 19

Electronic notes disadvantages:

Answer 19

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

Question 20

Content of the forms used to document are often determined by ____

Answer 20

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

Question 21

OT documents must:

Answer 21

• Contain info to justify the need for OT
• Demonstrate the provision of skilled interventions
• Show client progress toward identified goals

Question 22

Primary reimbursement systems for OT in phys-dis settings

Answer 22

The primary reimbursement systems for OT in phys-dis settings are: Medicare, Medicaid, various Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs)

Question 23

Medicare

Answer 23

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

Question 24

Medicare Benefit Policy Manual

Answer 24

The Medicare Benefit Policy Manual describes key phrases that medical reviews are looking for when reviewing claims

Question 25

Intermediaries will reimburse OT services only if

Answer 25

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

Question 26

Medicare 700 form

Answer 26

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

Question 27

Maintaining confidentiality in documentation is the responsibility of ____

Answer 27

Maintaining confidentiality in documentation is the responsibility of the OT

Question 28

Principle 3E of the AOTA code of Ethics

Answer 28

Principle 3E of the AOTA code of Ethics addresses privacy and confidentiality in all forms of communication, including documentation

Question 29

Guidelines to the Code of Ethics

Answer 29

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

Question 30

HIPAA

Answer 30

outlines the expectations of health care professionals in issues of confidentiality

Question 31

Protected health information (PHI)

Answer 31

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