Understanding Documentation OTA/PTA

Question 1

Purpose of Documentation

Answer 1

• Conveys essential information about pt’s diagnosis, treatment, and outcomes
• A measure of quality assurance
• Inadequate documentation affects patient care, safely, and outcome hence why there is a legal responsibility to complete it correctly
• A way to organize thoughts and problem solving

Question 2

Types of Documentation Notes

Answer 2

• Initial note (IA)
• Interim/Progress note(s) (PN)
• Discharge note (D/C)

Forms:
- Flow chart, d/c sheets

Question 3

Guidelines

Answer 3

• Documentation is required to reflect every visit/encounter with the pt
• Must be accurate
  - Factual statements
  - Objective (measurement) information pt information
• Handwritten entries should be written with ink and an original signature
• Draw a single line across the error with the initial and date on the side then add the corrections
• Consent must be obtained, recorded, dated

Question 4

College of Occupational Therapists of Ontario (COTO)

Answer 4

• A regulatory organization that oversees the practice of occupational therapists in Ontario
• OTs are responsible to know and maintain the standards (11 standards)

Question 5

11 Standards in the Document That Must Be Upheld (COTO)

Answer 5

1. Clinical Record Information
2. Documenting Receipt of Delegation of Controlled Acts
3. Organizational Administrative Matters
4. Application of Signature
5. Privacy and Access
6. Confidentiality and Security
7. Retention and Destruction
8. Discontinuation or Transfer of Practice
9. Financial Records
10. Equipment Records
11. Records Available to the College

Question 6

College of Physiotherapists of Ontario (CPO)

Answer 6

• Responsibility and accountability (organized, understandable, and accurate)
• Must adhere to privacy requirements
• Must follow retention regulations 10 years
• Financial records
• Must include the rationale for treatment, objective data, evidence, and outcome measures when possible
• Must contain enough details to allow another HC provider to continue Tx

Question 7

Competency Profile for Physiotherapist Assistants in Canada

Answer 7

Competency Profile Category List:

1. Performs Selected Measures or Tests
2. Reports Client Information to Enhance Physiotherapist’s Assessment/Reassessment Process
3. Develop, Build & Maintain Collaboration with Client and HC Team
4. Communicates in Professional Manners
5. Employs Effective and Appropriate Written and Electronic Communication

Question 8

1. Competency Profile for PTA: Performs Selected Measures or Tests

Answer 8

• “Collects qualitative and quantitative data related to the client’s physical status and functional ability within set parameters”.
• Monitors client responses and status during the performance of assigned measures/tests (e.g., shortness of breath, pain) and takes appropriate action, including reporting the findings to the physiotherapist”.
• “Reports the results of tests (e.g, documentation, verbal report)”.

(National Physiotherapy Advisory Group, 2012)

Question 9

2. Competency Profile for PTA: Reports Client Information to Enhance Physiotherapist’s Assessment/Reassessment Process

Answer 9

• “Communicates new information to the physiotherapist in a complete and timely manner (e.g., client’s family situation, home environment, health status)”.

(National Physiotherapy Advisory Group, 2012)

Question 10

3. Competency Profile for PTA: Develop, Build & Maintain Collaboration with Client and HC Team

Answer 10

• “Demonstrates sensitivity to the uniqueness of others”.
• “Uses various strategies of verbal and non-verbal communication”.
• “Demonstrates an awareness of self-behaviours and responses of others, and adapts communication appropriately.”
• “Respects confidentially and privacy”.
• “Identifies and addresses conflict in a timely and respectful manner”

(National Physiotherapy Advisory Group, 2012)

Question 11

4. Competency Profile for PTA: Communicates in Professional Manners

Answer 11

• “Uses audience appropriate language, strategies and material”.
• “Responds to questions within knowledge and skill level, or refers as appropriate”.
• “Seeks assistance or clarification as necessary”.
• “Conveys information in a timely manner”.

(National Physiotherapy Advisory Group, 2012)

Question 12

5. Competency Profile for PTA: Employs Effective and Appropriate Written and Electronic Communication

Answer 12

“Produces written and electronic documentation (e.g., health records, patient hand-outs) that is accurate and precise, using appropriate terminology”.

(National Physiotherapy Advisory Group, 2012)