Exam 1: Documentation and Treatment Planing

why do we document?

Maintain a serial record of services rendered: what did I do?

Communication: see what other professions document

To get paid for our services: reimbursement

Quality assurance: are we doing best practice? are they achieving goals?

Research

Who pays for OT services?

1) Patient -> self pay

2) Insurance companies -> HMO (limited) or PPO (out of network)

2) Federal and state funded programs --> medicare and medicaid, VA

3) Employer ->workers comp

4) Auto-insurance -> motor vehicle accident

5) Other funding sources -> grants

medicare vs medicaid

care: Provided health care to elderly + FEDERAL

aid: Provided health care to poor people + FEDERAL + STATE

if there is no documentation...

it never happened

documentation records should be...

Organized

Legible

Concise

Clear

Accurate

Complete

Current

Objective

Correct grammar

Proper spelling

parts of the documentation process

1) initial evaluation report

2) progress note or progress summary

3) discharge summary

what does the initial evaluation report consist of? when is it done?

-first encounter

-occupational profile

-select instruments

-administer evaluation

-develop treatment plan

what is the first step of the documentation process?

initial evaluation report

what does the progress note/summary consist of? when is it done?

-during treatment

-SOAP note

-narrative note

-each setting has different doc requirements

ex: rehab -> talk about ADLs

ex: school -> talk about academic interventions

what is the second step of the documentation process?

progress note/summary

what does the progress note/summary consist of?

note performance:

-before

-during services

-now

-moving forward

what is the third step of the documentation process?

discharge summary

what is important to put on every page of the documentation

patient identifier (name, id ...)

what goes on the documentation records of OT patients?

1) Patient identifier on each page

2) Date, time and length of intervention -> (time in/out)

3) Type of documentation (Initial, Progress , Discharge)

4) Practitioner's signature (First name or initial, Last name, Professional designation)

where does the OT signature go on the documentation form?

end of note

in addition to a practitioner's signature, what might also be required?

a countersignature

when can we use abbreviations when documenting?

1) when they are acceptable

2) when they are approved by the facility

when documenting in paper, what is to be done when you make an error?

errors are corrected by drawing a single line through the word and initialing it

EMC?

electronic medical record

what is required for a practitioner to begin treatment?

a prescription

*especially for insurance

what is important to document for someone to receive treatment?

1) recent documented change in condition (decline in prior level of function --> OT is necessary!)

2) reasonable expectation for progress (rehab potential)

3) ongoing process

*must reflect need for skilled services

*care must reflect standard of practice

rehab potential

reasonable expectation for progress

- excellent, good, guarded, no (avoid using poor)

skilled services

services that must be performed or supervised by a licensed healthcare professional

OT vs wife

medicare only reimburses for what type of services?

skilled

*other payers tend to follow these guidelines

skilled services require the knowledge and training of a

professional

is the following term skilled or unskilled terminology: assess

skilled

is the following term skilled or unskilled terminology: analyze

skilled

is the following term skilled or unskilled terminology: maintain

unskilled

is the following term skilled or unskilled terminology: help

unskilled

is the following term skilled or unskilled terminology: watch

unskilled

is the following term skilled or unskilled terminology: observe

unskilled

is the following term skilled or unskilled terminology: interpret

skilled

is the following term skilled or unskilled terminology: modify

skilled

is the following term skilled or unskilled terminology: facilitate

skilled

is the following term skilled or unskilled terminology: inhibit

skilled

is the following term skilled or unskilled terminology: practice

unskilled

is the following term skilled or unskilled terminology: monitor

unskilled

is the following term skilled or unskilled terminology: establish

skilled

is the following term skilled or unskilled terminology: instruct/educate

skilled

is the following term skilled or unskilled terminology: fabricate/design

skilled

is the following term skilled or unskilled terminology: adapt

skilled

is the following term skilled or unskilled terminology: environmental modifications

skilled

is the following term skilled or unskilled terminology: determine

skilled

what conditions are likely to use the word "maintain" during the documentation process?

neurological conditions --> dementia

Any kind of documentation and treatment must show:

medical necessity for OT

-complications and safety issues related to limited occupations performance and occupational engagement

examples of conditions that demonstrate medical necessity for OT:

1) poor posture (functional mobility, safety)

2) weak grip (ADLs)

3) paresis (motor weakness, neuro. cond., safety)

4) perceptual deficits

5) cognitive disorders

first step of OT process

conduct and evaluation/assessment

what does the first evaluation/assessment consist of?

1) establish medical necessity -> after doc prescribes OT

2) highlight the need for skilled services (ex: patient lives alone and cannot prepare a meal)

3) states a change in condition (independent --> dependent)

4) states a profess expectation --> rehab potential

the evaluation/assessment must be completed when?

prior to providing any interventions

- evaluate before you assess

initial evaluation documentation includes:

1) reason for referral

2) client information (diagnosis)

3) occupational profile (past + current level of function)

4) assessment tools utilized and results (analysis of findings and justification for OT services + rehab potential)

5) expected outcomes and recommendations

what is the purpose of an intervention plan?

to design or propose a therapeutic program

an intervention plan is based on ...

one or more FOR

functional OT problem list consists of

affected area of occupation + contributing factors

* part of intervention plan

two types of goals

short term and long term

goals must be

measurable and attainable

in terms of time, intervention plans must provide

frequency and duration of treatment

types of intervention approaches

create/promote

establish/restore

maintain

modify

prevent

steps of treatment planning

1) evaluate occupational performance

2) identify functional OT problems

3) establish the LTG for each OT problem

4) establish a STG for each LTG

5) select intervention methods

provides a standard for measuring the progress

intervention plan??

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

the intervention plan?

functional OT problems are composed of

affected occupation + contributing factors

what does an OT do to evaluate occupational performance?

1) conduct an patient interview

2) observation

3) administer assessments

4) gather data

5) consider: pre-morbid status, current status, predicted status

when evaluating occupational performance, what client factors are important to consider?

age

education

culture

psychological status

functional status

where can we get info to get to know our client better?

-the patient themselves

-medical record

-assessments

-observing the patient

-other team members

-family/significant others

-resource materials

when gathering information about the client, what must we make sure to do?

access iff its valid!

how do we identify functional ot problems?

1) analyze evaluation results

2) use OTPF domains

- areas of occupation

- client factors

- performance skills

- performance patterns

- context

- activity demands

all of your treatment planing depends on

your clients functional problem

when determining your clients functional problem, what are two questions that we can ask ourselves?

1_ what aspect of occupational performance is affected?

2_ what factor is hindering performance?

an area of occupation might be impacted by

several influencing factors

ex: impaired ability to type; cognitive, ROM, fine motor coordination, others?

an influencing factor may impact

several areas of occupation

ex: poor endurance; community mobility, home management, mealpreparation, others?

reasonable expectation for performance of OT problem at discharge

LTG

LTG must be:

1) client -centered

2) occupation-based

3) measurable and observable

4) functional

5) attainable

stepping stones to reach LTG

STG

every LTG will have

at least one STG

what happens when a client reaches a STG?

a new one is written until the LTG is reached

T/F there is one correct way to write a well constructed goal

false

There is no ONE correct way to write a well constructed goal

T/F there are many ways to write a poorly constructed goal

true

format for writing goals

COAST

what does COAST stand for? what is it used for?

goal writing

C- client

O - occupation

A - assistance

S - specific conditions (not required*)

T - timeframe

OT services are an ongoing process, what does this mean? what do we have to be aware of?

- are goals being met?

- if not, do we need to modify the plan?

- determine if we need to: continue, discontinue, referral