Documentation (6.2)

Who reads our documentation?

• Medical professionals

• Education professionals

• Legal professionals

• Accreditation agencies

• Insurance companies

• Client/guardian

Legal and Ethical Considerations for documentation:

• Malpractice

• Fraud

• Negligence

• Incompetence

• Ethical issues (timely records, rules & regulations, falsified records, inaccurate coding)

Who’s responsible for our documentation as OTR:

Myself

Who’s responsible for our documentation as OTA:

You as well as the OT

2 Requirements for reimbursement:

Skilled and Medically Necessary

What does Skilled treatment mean:

Requires the knowledge and clinical reasoning of an OT

• Explain why an OT was needed to complete this

What does Medically necessary mean:

Treatment addresses the client’s diagnosis, functional needs, and plan of care

• is also reasonable and appropriate for client’s condition and goals

AOTA guidelines for documentation:

should meet the ethical standards, scope of practice, and regulatory requirements

Domain vs. Process

Domain: the outer circle - occupations, contexts, client factors, performance patterns, performance skills

Process: Intervention, evaluation, process

• Use the domain to create the process for your specific client

Evaluation:

Initial evaluation

• Assessment portions: OT profile (subjective) & Analysis of Occupational performance (objective)

• Interpretation portions: clinical reasoning, problem statements, goals, recommendations, other referrals

Re-evaluation

What’s included in an Evaluation report?

• Identifying and background information: name, age, dx, referral date, precautions/contraindications

• Referral Information

• Evaluation procedures/assessments used

• Occupational profile

• Findings or results of evaluation process

• Interpretation of findings

• A plan

• Signature and credentials

What’s included in referral information and where does this go?

Evaluation report

• Date, time, who referred the client and why

What’s included in a plan during an evaluation report

Goals, frequency, duration, and location of intervention

Intervention documentation:

Treatment (tx) notes: SOAP

Progress report: summary of sessions

Outcomes documentation:

Discharge report

• summary of care

• performance and functional status

• recommendations

Daily notes should include

Subjective: experience of the client

Objective: clinician’s objective observations/measurements

Assessment: clinician’s interpretation of the O

Plan: Next steps (frequency, duration, and location)

SOAP abbreviaiton meaning:

Subjective

Objective

Assessment

Plan

Subjective example:

Client states that it hurts to reach items on the second shelf, and they can’t put their hair in a ponytail

Objective example:

Goniometry, where exactly the pain is located, how the client compensates their bodily movements, pain scale

Assessment example:

Limited ROM, that interferes with occupations (list them)

Plan example:

OT 2x weekly for 30 minutes, and describe what will be focused on during this time

When is discharge summary needed?

Goals are met or services end

What’s included in a discharge summary?

• Client identification/background information

• Client functional status

• Summary of change in functional status

• Results of outcome measures

• Follow-up recommendations

• Signature, credentials, and date

Problem statements

Develop a functional problem that includes measurable information that will help document progress towards goals

Problem statement example:

Poor trunk control and limited R UE grasp patterns limit child’s ability to feed self with utensils

Goal should be…

Based on the problem list

• Occupation-based

• Measurable

• Action-oriented

• Realistic

• Achievable in a certain timeframe

Focus on Goal Writing:

Functional improvement that leads to meaningful engagement

Goal Format acronym:

COAST:

• Client: person performing the behavior

• Occupation: will perform what occupation (action based)

• Assist Level

• *Specific Condition: location, using a certain technique, using equipment

• Timeline: length of time to complete goal

LTG:

Long term goal

STG:

Short term goal

Ideal Goal Statement:

By the time of d/c in two weeks, client will dress himself with minA for balance using a sock aid and reacher while seated in w/c

STG definition:

Smaller increments of progress that facilitate the LTG

• often have several of these to support one LTG