Referral and Screening Flashcards
What is a referral?
A suggestion
You don’t have to see the client
Who can we get a referral from?
No federal rules
State licensure and payer policy
MD
DO
OD
PT?
DS
Who can receive and respond to a referral?
OTR
COTA cannot accept a referral
COTA can schedule a pt
Who can refer to others?
OTR
COTA can make suggestions on referrals and set up referral apt
We are required by AOTA, Standards of Practice to refer when appropriate:
- outside our knowledge base
- personal issues
- others with expertise
What is the difference between order and referral?
Care/treatment plan
Often substitute for orders
Specific or very detailed
Care plans
- Medicare requires recertification every 30 days for outpatient (60 for homecare)
Physician’s signature
Can a physician change the care plan?
No
What should a referral or care plan have?
Full name of client
Date
Reason for referral (usually the order or may be the diagnosis)
Full name and usually signature of physician
Frequency and duration of OT services
- Sometimes the intensity (length of session)
What if I get a referral that says “evaluate and treat”?
- evaluate and treat
What is a screening?
Brief check to see if a client needs further eval, referral or intervention
Usually not reimbursable
Can be done without physician order or referral
COTA can perform screen but not interpret
What are the types of screenings?
Type I-routinely screening individuals in a particular setting …ex: you work in home health and all patients admitted are screened for OT
Type II-screening after a referral has been received
What are the guidelines for using a screening system?
Screens should be within the scope of your practice, you would not screen for diabetes
Screens should be timely, when services will be effective… you wouldn’t screen for developmental delay in 18 year olds
You should have reason to believe the population you are screening is at risk or in need of your services
Intervention must be available: “ you need OT, but we don’t have an OT”
Screen should be based on valid and reliable methods, does not mean standardized
What are the possible outcomes after a screen?
- Client needs OT evaluation and treatment
- Client has some issues, but not severe enough to warrant OT at this time, but rescreen at a specific time
- Be careful here!! By Law (when dealing with school system) this must be based on the client and NOT the availability of staff… ethically this applies to all other areas
* EX: I work on a burn unit with severe burns, my schedule is packed and I get an order to see a client with a small 3rd degree burn, no graft - Client is out of scope of OT or out of your scope
- Ex: Pt seen for shoulder pain, you suspect the problem is cardiac
- Pt is sent to you for lymphadema therapy, the therapist down the street is a certified lymphadema specialist - Client doesn’t need a thing
What is a COTA’s role in screening?
The OTR is responsible for conducting the screening
- The COTA can assist… perform a simple test, do a questionnaire ect
The OTR is responsible for selecting the appropriate tools for the screen
The OTR is responsible for determining the recommendation
- The COTA may report it to others
ONLY the OTR may refer the client to other sources
What is a contact note used for?
To document the order/referral was received
To document a screen was performed
To document communication between OT and other health care professionals or between OT and COTA
To document recommendations for equipment
To document recommendations to family or caregiver or training
To document missed visits
What is a contact note?
A brief note in the medical record
