Regulatory Issues: Documentation (Week 14)

Question 1

Purposes for Client Care Documentation

Answer 1

1. Client care management
2. Referral for other services
3. Reimbursement
4. Utilization review and management
5. Legal document
6. Quality management
7. Accreditation
8. Education and research
9. Business development and management
10. Client access

Question 2

Documentation in OT

Answer 2

1. Documentation follows the OT process
   -Initial evaluation
   -Intervention planning
   -Intervention
   -Intervention review
   -Outcomes
2. Documentation uses Professional language (OTRF) (Domain and Process)

Question 3

Health Records

Answer 3

-Any part of documentation is part of the health record
-Depending on the setting, health records are mainly electronic
-Organized by source-oriented information, integrated information, problem-oriented

Question 4

Types and Formats of Documentation

Answer 4

-Types (Handwritten, electronic, mixture)
-Formats (SOAP, DART, PIE, SOAPIE, SBAR, Narrative, Mixture, etc.

Question 5

Documentation Notes

Answer 5

1. Client name
2. Type of documentation
3. Date of service
4. Problem/goal
5. What the client did
6. Skilled service provided
7. Referrals
8. Signature

Question 6

Documentation Rules

Answer 6

1. Witten in pen if on paper
2. Have a date
3. Professional terminology
4. Acceptable abbreviations
5. Legibility
   6.

Question 7

SOAP Notes

Answer 7

1. Subjective
2. Objective
3. Assessment
4. Plan

Question 8

Subjective

Question 9

Objective

Question 10

Assessment

Question 11

Plan

Question 12

Structures and systems that create and impact federal and state legislation and regulations

Question 13

AOTA

Question 14

MBOT

Question 15

Payment for Services

Answer 15

1. Medicare
2. Medicaid
3. IDEA: Part B/C
4. Workman’s Compensation
5. Medical Insurance
6. Tricare
7. Grants
8. State Grants
9. Quadruple Aim

Question 16

Payment Rules: Medical Settings

Question 17

Influence of Payer Systems on Documentation

Question 18

Documentation Legislation

Question 19

Ethical Considerations

Question 20

Billing for Services (Reimbursement)

Answer 20

1. Practice can be “transformed” by changes in reimbursement
2. Important for all therapists to know and understand payment systems
3. Public policy affects all of us as consumers and professionally