Exam 1: Documentation and Treatment Planning

Why do we document?

1) maintain a serial record of services rendered

2) communication with other disciplines

3) to get paid for our services

4) quality assurance (providing best practice, pt goals)

5) research (retrospective analyses)

Who pays for our services?

patient: self-pay

insurance companies

-HMO or PPO

federal and state funded programs

-medicare (federal)

-medicaid (federal and state)

-VA

employer

-workers comp

auto insurance

other funding sources

-grants

What is HMO?

Health Maintenace Organizations

-insurance group that provides health services for a fixed annual fee

-there is an agreed-upon payment level

-CAN'T go out of network

What is PPO?

Preferred Provider Organization

-provide medical services at preset, usually lower fees, in return for a large number of referrals

-CAN go out of network

When documenting OT services, records should be...

-organized

-legible

-concise

-clear

-accurate (truth/veracity)

-complete (didn't document it? it didn't happen)

-current (don't wait 4ever to document)

-objective

-correct grammar

-proper spelling

What are the 3 types of documentation?

1) initial evaluation report

2) progress note or progress summary

-SOAP note

-narrative note

(each setting has diff. doc. requirements i.e. ADLs in in-pt rehab is diff from interventions in school-based OT)

3) discharge summary

When documenting OT services, you should always include...

patient identifier on each page

date, time, and length of intervention (time in/out)

-ex: "pt seen on 5/13/2024 for in-pt rehab for 30 mins focusing on ADL training"

type of documentation

-initial, progress, discharge

practitioner's signature

-first name or initial, last name, professional designation

-directly at end of note

-countersignature if required (i.e FW student)

acceptable terminology

facility-approved abbreviations

if not using EMR, errors corrected by a single line through error with your initial next to it

Is a prescription required for tx?

YES

-no Rx, no reimbursement

(diff with ppl who are self pay OUTSIDE of clinic i.e. a friend who wants OT from u)

What are the documentation guidelines?

prescription is required

recent documented change in condition

-was there a decline in prior level of functioning that you should document?

reasonable expectation for progress (rehab potential)

-excellent, good, fair, guarded (poor)

ongoing progress

care must reflect standards of practice

-dont continue to tx if pt is not progressing/no rehab potential

plan must reflect need for skilled services

Services that require the knowledge and training of a professional

skilled service

T or F. Medicare inly reimburses for skilled services.

TRUE

and other payers tend to follow these guidelines

Skilled terminology

assess

analyze

interpret

modify

facilitate

inhibit

establish

instruct/educate

fabricate

design

adapt

environmental modifications

determine

Unskilled terminology

Maintain

Help

Watch

Observe

Practice

Monitor

What constitutes OT medically necessary?

complications and safety issues related to

-limited occupational performance and occupational engagement

examples

-poor posture

-weak grip

-paresis

-perceptual deficits

-cognitive deficits

T or F. poor posture, weak grip, paresis, perceptual deficits, and cognitive deficits can constitute the need for OT.

true

What is the first step in treatment?

conduct a screening then determine if evaluation is necc.

Evaluation/assessment is important because it......

-establishes medical necessity for OT

-identifies need for skilled services

-states a change in condition

-states a progress expectation (rehab potential)

must be completed prior to providing any interventions

T or F. Evaluations/assessments must be completed prior to providing any interventions.

true

screening comes first

Initial evaluation documentation includes...

reason for referral (why pt is seeking OT services)

client information (diagnosis)

occupational profile

-past level of function

-current level of function

assessment tools utilized and results

-analysis of findings and justification for OT services

-rehab potential

expected outcomes and recommendations

What does the intervention plan entail?

design or proposal for a therapeutic program

based on one or more FORs

functional OT problem list (affected occupation and attributing factors)

occupation-based goals (LTG & STG; must be measurable and attainable)

intervention approaches (modify, restore, etc.)

frequency and duration (2x a wk for 30 mins for 6 wks)

provides a standard for measuring progress

allows the OT to plan and analyze the proposed course of action

What is the process of treatment planning?

1) evaluate occupational performance

2) identify functional OT problems

3) establish the LTG for each OT problem

4) establish a STF for each LTG

5) select intervention methods

very basic LTG and STG example

LTG: prepare a 3-ingredient meal

STG: cut a carrot into bite size portions

How do you evaluate occupational performance?

evaluated through:

-patient interview

-observation

-administering assessments

-gathering data

be sure to consider:

-pre-morbid status

-current status

-predicted status given clinical picture

What should you always consider when evaluating occupational performance?

-pre-morbid status

-current status

-predicted status given clinical picture

-age

-education (literacy)

-culture

-psychological status

-functional status

Where can you gather patient info from when evaluating an occupational profile?

-medical records

-assessments

-observing the pt

-other team members/disciplines

-family/significant others (always be cognizant of this info, sometimes it played up or down)

-resource materials

How do you identify functional OT problems?

you analyze your pt's evaluation results

you refer back to the OTPF domains

-areas of occupations

-client factors

-performance skills

-performance patterns

-context

-activity demands

What is a functional OT problem? What does it contain?

contains two elements

1) affected area of occupation

2) influencing/contributing/attributing factor

all of your tx planning depends on this

be sure to ask yourself

-what aspect of occupational performance is affected?

-what factor is hindering performance?

T or F. an area of occupation may be impacted by several influencing factors and an influencing factor may impact several areas of occupation.

TRUE

one can affect the other and vice versa

examples

-occupation: impaired ability to type

-attributing factors: cognitive, ROM, fine motor coordination

-attributing factor: poor endurance

-occupation(s): community mobility, home management, meal prep

Child requires mod A to hold scissors to complete art activities in school due to high tone in R UE. What is the affected area of occupation? What is the contributing factor?

affected occupation

-hold scissors for art activities in school

attributing factor

-high tone in R UE

Client is unable to sustain employment for more than 2 weeks due to the absence of stress management skills. What is the affected area of occupation? What is the contributing factor?

affected occupation

-sustain employment

attributing factor

-absence of stress management skills

Reasonable expectation for performance of OT problem at discharge. This is the definition of what?

long-term goal

When establishing a LTG, the goal must be.....

LTG goal must be:

-client centered

-occupation-based (what makes it that only we can tx it, not PT, not the family, not SLP)

-measurable and observable

-functional

-attainable

Establishing a STG

-these are stepping stones to reach the LTG

-as a STG is achieved, a new one is written until the LTG is reached

-the time span to achieve a STG is not as long as reaching LTG

-STGs are frequently revised

-STGs must be related to LTG

T or F. A STG cannot be revised.

FALSE

STGs CAN BE REVISED!!!

T or F: the time span to achieve a STG is longer than achieving the LTG.

FALSE

the time span for STGs is NOT AS LONG!!!

What does COAST stand for?

Client

Occupation

Assist Level

Specific Condition

Timeline

What are the intervention approaches/methods?

create, promote

establish, restore**

maintain

modify**

prevent

create, promote

-an approach that does not assume a disability is present or that any factor would interfere with performance

-designed to provide enriched contextual and activity experiences that will enhance performance for all persons in the natural context of life

-creating programs to promote health and wellness for your patients

example

transitioning from healthy worker to retirement

establish, restore

-approach designed to change client's variables to establish a skill or ability that has not yet developed or to restore a skill or ability that has been impaired

-improving skills or abilities lost or impaired by illness or injury

example

working on ROM post wrist fx

maintain approach

-approach designed to provide supports that will allow clients to preserve the performance capabilities that they have regained and that continue to meet their occupational needs

-the assumption is that without continued maintenance intervention, performance would decrease and occupational needs would not be met, thereby affecting health, well-being, and quality of life

example

neurodegenerative disorders

modify approach

-approach directed at "finding ways to revise the current context or activity demands to support performance in the natural setting, [including] compensatory techniques . . . [such as] enhancing some features to provide cues or reducing other features to reduce distractibility"

example

energy conservation techniques for individuals with dyspnea secondary to COPD

prevent approach

-approach designed to address the needs of clients with or without a disability who are at risk for occupational performance problems

-designed to prevent the occurrence or evolution of barriers to performance in context

-interventions may be directed at client, context, or activity variables

example

fall prevention program for well, elderly adults

OT is an ongoing process which means we should always be on the look out for......

if goals are being met

modifying the intervention plan as needed

determining the need to

-continue tx

-discontinue tx

-referral to other disciplines