Occupational Therapy Documentation and Clinical Notes: Key Concepts and Best Practices

What do performance skills include?

The COTA examining and documenting how tasks are performed and what factors may impede function.

What is documented under Assessment?

A health professional's clinical judgement and interpretation of the statements and events reported during the treatment session.

What is the purpose of the health record?

To provide a legal document, exchange information between care providers, and be utilized for reimbursement purposes.

Give an example of a physical environment.

Elementary school.

What are the types of health records?

Client care management, reimbursement, the legal system, research/EBP, accreditation, education, public health, business development, the client, clinical, quality measures.

What is written at the end of a specified period of time?

Progress note.

What effect do spelling and grammar errors have on practitioners?

They may question your credibility, competence, or intelligence.

What is true about abbreviations?

Approved abbreviations vary from facility to facility.

How should academic degrees and professional designations after a person's name be written?

They need to be capitalized.

Can verb tenses switch throughout a note?

No, it is false.

What does 'ABD' stand for?

Abduction.

What does 'ADD' stand for?

Adduction.

What does 'BADLs' stand for?

Basic activities of daily living.

What does 'COTA' stand for?

Certified occupational therapy assistant.

What does 'HTN' stand for?

Hypertension.

What does 'OOB' stand for?

Out of bed.

What does 'F/U' stand for?

Follow up.

What does 'PAM' stand for?

Physical agent modality.

What does 'POC' stand for?

Plan of care.

What does 'VS' stand for?

Vital signs.

Why is it critical to reference the relevant occupation in documentation?

To indicate the functional purpose of the intervention.

How can the content of the O section of a SOAP note be written?

Chronologically or categorically.

It is important to include the date and time when documenting pertinent phone calls regarding a patient or client?

True

Effective documentation does NOT require that you hone your observation skills to increase accuracy

No, it is false.

What is not beneficial for increasing observation skills for documentation?

Noting how many pets the client has at home.

Why is it important to note what the client did before OT treatment?

It provides context for the intervention.

What is an accurate Objective statement?

Client was min A donning socks.

What are essential components that justify a reassessment?

Client is no longer making progress, significant changes in the client's situation, new clinical findings.

What are essential components that justify completing a discharge summary?

OT services are no longer justified, client has expired, client will continue OT service in a different setting.

What is true of long-term goals?

The timeframe may vary between clients and settings based on the condition of the client.

What does 'S' of COAST refer to?

Under what conditions.

Can a goal be written to address what a parent or caregiver will achieve with skilled instruction?

Yes, it is true.

What level of assistance would describe a client who can complete LB dressing with 45% assistance?

Partial/Moderate Assistance.

What type of note is used to document a typical intervention session?

Contact.

What type of note is used for documenting a hands-on caregiver training session?

Contact.

What type of note summarizes new information about a patient?

Reevaluation.

What type of note summarizes the intervention process and documents patient progress?

Progress.

What is not typically reported in a progress note?

Reasons for discontinuing occupational therapy services.

Match the facility setting: - Home health. 

Outcome and assessment information set data collection method is used

Match the facility setting: Early intervention 

Uses a family-centered plan that contains specific information about the child's developmental status, family situation, and assessment results. It designates a service coordinator for the child's care

Match the facility setting: Skilled nursing facilities.

Therapy logs are used to keep track of day-day interventions, and progress notes are completed at regular intervals

Match the facility setting: Inpatient rehabilitation facilities.

Documentation focused on clients progress, functional improvement, and intervention focused on returning client's safe return home or to a community-based environment upon discharge. Contact notes are used after each treatment session

Match the facility setting: Acute care. 

Length of stay is generally brief, so formal reevaluation reports are rarely needed. Contact notes are written after each treatment session to communicate therapeutic interventions, progress or changes in client's condition, and current functional status

Match the facility setting: School based practice.

IEP- Individual Education Program