PPT - Intro to Documentation

Question 1

The Medical Record (MR)

Answer 1

Can be used as evidence in court, need to document accurately and adequately to support services (or can be denied payment by insurance companies and therapists can lose licensure/face penalties)

Purpose of the MR

• Record of patient conditions, eval, and re-eval
• Document intervention and patient response to that intervention

Question 2

Documentation General Standards

Answer 2

• Be legible, professional, objective, current and clear
• Follow institution guidelines
• Use good grammar and spelling, syntax, word choice
• Concise and complete
• Avoid slang and use professional titles
• Use standard and “well-recognized “abbreviations
• Person first language
• Date: month, day, year
• Signature and date/time of signature - Full name and credentials
• • Sign immediately after the content you document, no blank lines/ empty spaces
• • Co-sign OTA/OTS (if required)
• • Can be denied payment by Medicare if signature is not legible
• Label the document
• Client name, ID# on each page
• Don’t white out/block out information
• Maintain HIPAA (confidentiality even outside)
• *All documentation subject to subpoena…be sure to adhere to all standards *

Question 3

OTA Documentation

Answer 3

Recommended by AOTA to be in the medical record and should be co-signed by OTR because the docs could get subpoenaed and shows compliance to laws/regulations, but not required

Question 4

Initial Evaluation and Re-evaluation

Answer 4

Initial: chart review

Eval and Re-eval: assessment and results, summary and analysis of assessment findings, OT problem list/areas for improvement, recommendation for OT services, intervention goal/plan, client involvement, recommendations/referrals

Question 5

Goal Writing: SMART

Answer 5

Specific
Measurable
Attainable
Relevant
Time-limited

Question 6

Discharge Report

Answer 6

• Summary of eval and intervention
• Compare initial and discharge status
• Reason for discharge
• Recommendations
• Disposition