Documentation for the OTA

Vocabulary flashcards related to documentation in Occupational Therapy, covering key terms, concepts, and reports used by OTAs.

SOAP Note

Subjective, Objective, Assessment, Plan - a format used in healthcare documentation to organize patient information and track progress.

ICF (International Classification of Functioning, Disability and Health)

Consists of descriptions of all aspects of human function and disabilities, providing a common language for information sharing and international policy planning.

ICF Components

Body structures and function; Activities and Participation.

OTPF (Occupational Therapy Practice Framework)

Six domains of Occupational Therapy practice.

Occupational Profile

A client-centered approach to gathering information to determine contextual or environmental features, activity demands, or individual client factors that need to be addressed.

Occupational Profile Components

Occupational history, interests, experiences, habits, patterns of daily living, client values and needs, and client's hopes to gain from the present situation.

Occupational Profile in Service Delivery

An initial step in the evaluation process that provides an understanding of the client’s occupational history and experiences, patterns of daily living, interest, values, and needs; problems and concerns about performing occupational and daily life activities are identified, and the client’s priorities are determined.

Analysis of Occupational Performance

The step in the evaluation process during which the client’s assets, problems, or potential problems are more specifically identified.

Intervention Plan

A plan that will guide actions taken and that is developed in collaboration with the client, based on selected theories, FOR, and evidence; outcomes to be targeted are confirmed.

Intervention Implementation

Ongoing actions taken to influence and support improved client performance; interventions are directed at identified outcomes, and the client’s response is monitored and documented.

Intervention Review

Review of the implementation plan and process, as well as its progress toward targeted outcomes.

Outcomes

Determination of success in reaching desired outcomes; outcome assessment information is used to plan future actions.

Activity Demands

Interactive demands of an activity; documentation should always include contextual and environmental issues or problems with appropriate intervention follow-up.

Client Factors: Body Structures

Provide a base of stability for body systems to function; some problems can be fixed temporarily/permanently.

Client Factors: Body Functions

Body systems perform their duties; vital processes of basic life and movement.

Performance Skills

Client behaviors and actions grouped into five areas: emotional regulation, motor and praxis, cognitive, sensory-perceptual, and communication and social.

Documenting Performance Skills

Observe and analyze performance skills, document how task is performed and what factors may impede function; document professional observations and analysis of behaviors, actions, skills and underlying factors in SOAP note.

ADL

Activities of Daily Living

IADL

Instrumental Activities of Daily Living

Eight Areas of Occupation

Occupations including ADL, IADL, Work, Leisure, Play, Education, Social Participation, and Rest and Sleep.

Roles of the OT and OTA in Documentation

OTA partners with OT in designing, implementing, and assessing OT services; OT professionals are responsible and accountable for adhering to the mandatory policies and procedures adopted by state and federal regulatory agencies regarding documentation.

Types of Notes

Notes documenting the OT intervention process varying according to the practice setting, from the first notation of referral to the closing line of discharge; specific content, format, organization, and timelines required all vary.

Initial Evaluation Reports

Used before beginning tx to determine if OT is appropriate and what kind of therapeutic intervention will be most useful.

Contact Notes

Each time intervention is provided a notation is made of what occurred (varies in settings) (SOAP).

Progress Report

End of a specified period of time; record progress toward goals and details any changes in intervention plan.

Reevaluation Report

To be recertified for treatment after the number of initially allocated visits are completed; modify according to client’s progress/needs

Transition Plan

When a client is transferring from one service setting to another; ensure client’s intervention plan remains intact.

Discharge or Discontinuation Report

End of tx written to describe changes in the client’s ability to engage in meaningful occupation as a result of OT intervention; summarize the course of treatment, progress toward goals, status at time of discharge; recommendations, provision or AE/DME, splints, HEP.