Unit 7: Documenting the Evaluation

Question 1

Evaluations

Answer 1

Need to convey to clients, third-party payers, and other professionals both the unique needs of the client and how OT is medically needed to address those needs

Question 2

The Evaluation includes:

Answer 2

• Client Information
• Referral Information
• Occupational Profile
• Assessments used and results
• Analysis of occupational performance
• Summary and analysis
• Recommendations

Question 3

Eithin the evaluation process, it is important to acknowledge…

Answer 3

The role of other professionals and make recommendations for services beyond the OT scope of practice.
-Integrating assessment data with clinical reasoning and providing a coherent document to demonstrate need is one of the more essential tasks of an occupational therapist.

Question 4

Client information:

Answer 4

-Record the patient’s name, date of birth, sex, health status, medical history, medical/educational/developmental diagnosis, precautions, and contraindications.

Question 5

Why are the aspects of client information important to include in documentation?

Answer 5

• It makes a difference in terms of reimbursement and demonstrating whether your client is receiving a low-, medium-, or high-complexity evaluation.
• Identifying the client appropriately in the medical records is essential to keeping fidelity across medical records and making the electronic health record a source of information and education that can be used across settings.

Question 6

Recall the information about reimbursement and the merit-based incentive payment system for outpatient therapy: One of the requirements for reimbursement is… (client information)

Answer 6

• The quality use of electronic medical records to communicate with other stakeholders.
• Ensuring consistent and appropriate documentation even at the most basic level of client information is important.
• Making sure to document the specific medical history, health status, primary and secondary diagnosis, precautions, and contraindications also helps you to explain why your evaluation should be reimbursed at a low-, medium-, or high-complexity rate based on the new evaluation CPT codes.
• This is not the section to rush through or omit information from. Sometimes you will need to go to the person’s medical record, MDS coordinator, caregiver, or contact previous or current medical providers for information.

Question 7

Referral information:

Answer 7

• Include the date and source of the referral, as well as the services that are requested, the reason for the referral, the funding source, and the anticipated length of stay.
• Sometimes this information will be included in the section where client information is also found.

Question 8

With regard to the referral information, you want to be sure that you include…

Answer 8

• The functional reasons that the client has been referred for services.
• Saying that the client was referred for services for evaluation and treatment by the physician does not give the reader information about the functional reasons for OT to be involved in the client’s case.

Question 9

Information about the referral may come from…

Answer 9

Your screening process, family members, the client, or documentation from previous medical visits.

Question 10

Occupational Profile

Answer 10

• The more subjective section of your evaluation, where you reporting the reasons for OT services and the areas of occupational functioning that the client is succeeding in or is being challenged in.
• You will also describe the Environmental Factors and Personal Factors related to occupational performance and any history that’s relevant to the client’s diagnosis and current performance.
• This section also describes the client’s motivation and goals for participating in therapy.

Question 11

The occupational profile should demonstrate…

Answer 11

• A clear functional need for skilled occupational therapy services
• A previous history that demonstrates a significant difference between prior level of functioning and current level of functioning
• A willingness on the client’s part to be engaged in the therapy process.

Question 12

The Occupational Profile section requires clinical reasoning and critical thinking to ensure that…

Answer 12

You are including only relevant information while being detailed enough to indicate the need for therapy services.

Question 13

Assessments used and Results

Answer 13

• More objective in nature and includes the types of assessments used and results reported from the evaluation process.
• Observations, standardized and nonstandardized assessments, and interviews should all be included in the section.
• Here you are stating the facts.
• Include which specific assessments were performed and what the results were, with minimal interpretation (sometimes achieved using a chartlike format)

Question 14

It is important to report the exact results of the assessments as… (assessments and results)

Answer 14

You completed them and describe any alterations in assessment performance that should be noted by future clinicians involved in the client’s care.
-Ex. were evaluations performed during separate time periods due to a client’s fatigue, or did you have to skip a section of an assessment because the client was unable to complete the task? This type of information makes documentation more reliable and ensures that reevaluations and discharges will accurately reflect a client’s progress and performance over time.

Question 15

Analysis of occupational performance:

Answer 15

• Let your occupational therapy knowledge and clinical reasoning shine.
• The analysis section provides the description and evaluation of the performance skills, performance patterns, context and environment, activity demands, and outcomes that you determined based on your interpretation of standardized and nonstandardized assessments.
• Requires you to take the data from the evaluation process and give it meaning (not enough to restate the results you found)
• Results need to be connected to a functional performance and occupational engagement.

Question 16

Results need to be connected to… (analysis of occupational performance)

Answer 16

• A functional performance and occupational engagement.
• For example, restating that somebody scored 16 on the Montreal Cognitive Assessment (MoCA) is no different than listing scores in the assessments used and results section. In this section you need to expand on the data and explain which areas of the assessment the client struggled in—which could relate to performance skills or client factors.
• For example, you might report that “the client demonstrated difficulties in performing visuospatial activities, especially the clock-drawing task.” The details provided in this section build your justification for providing skilled services.

Question 17

Summary and Analysis

Answer 17

Includes an interpretation of the entire evaluation process:

• It incorporates the occupational profile information along with the referral concern and the assessment data to demonstrate a need for skilled services.
• Should clearly indicate functional-based problem statements that align with the client’s prior level of functioning, current level of functioning, referral for skilled services, diagnosis, client-stated goals, and assessment results.

Question 18

Recommendations

Answer 18

Provides information about:

• The appropriateness of occupational therapy services
• The length of occupational therapy services recommended
• The types of services that may be provided with an OT
• A referral to other practitioners who should be involved in the client’s care.
• This is a great section for us to demonstrate our knowledge of the interdisciplinary care team and participate in care coordination and care management of the client.

Question 19

Tips and tricks: As with our previous discussion of documentation, there are similar tips and tricks for making your evaluation shine. These include the following:

Answer 19

1. Focusing on the client as opposed to the therapist
2. Clearly demonstrating a difference between the client’s goals and/or prior level of functioning and their current level of performance
3. Showcasing the need for skilled services
4. Using appropriate terminology, abbreviations, punctuation, grammar, formatting, and spelling to ensure clarity
5. Keeping the service delivery model, payer source, setting, and interdisciplinary care team in mind
6. Using a clinical format for writing, which includes concise, specific language with simple sentences that have a clear purpose and action (this writing is considered more expository and persuasive than narrative or descriptive, such as what you would read in a novel).