OT 504 Week 1 SG : Intro to the Occupational Therapy Process and Documentation.

What are the main steps of the OT process?

Referral/Intake → Evaluation → Treatment → Discharge/Re-evaluation.

According to the OTPF, what are the three major process components?

Evaluation, Intervention, and Outcomes.

Which part of the OT process is OT-only?

Evaluation.

Where may OTs collaborate with OTAs?

Throughout the OT process continuum.

during the OT evaluation what occurs?

develop an occupational profile, assess the client/patient, and determine plan of care

what happens during the step of provide treatment?

provide interventions/adapt or modify the environment

what happens during the reevaluation/discharge stage?

determine if the goal has been met

What occurs during referral/intake?

The client enters OT services, often through a referral and sometimes an initial screening/evaluation.

Does the referral process look the same in every practice setting?

No, it varies across practice areas and sites

What is the purpose of the occupational profile?

To identify the client's interests, strengths, weaknesses, barriers to participation, and goals.

Why is client collaboration important when developing goals?

Clients are more likely to engage when goals are meaningful and collaborative.

What are components of an occupational profile?

Prior medical and occupational history, current health, strengths/weaknesses, barriers, roles, habits, routines, environment, and goals.

What information is included in prior occupational history?

the client's previous occupations, roles, routines, and participation patterns.

Why are roles, habits, and routines important?

Disruptions in these areas can negatively affect occupational participation.

What are the three major parts of evaluation?

Occupational profile, screening/assessment, and plan of care development.

What occupation areas may be assessed during evaluation?

ADLs, IADLs, work, sleep, and roles/responsibilities.

Give examples of ADLs.

Toileting, dressing, and functional mobility.

Give examples of IADLs.

Financial management, food preparation, and medication management

What are the three categories of performance skills?

Motor skills, process skills, and social interaction skills

What are motor skills?

Skills related to positioning the body and sustaining performance.

What are process skills?

Skills involving applying knowledge and organizing actions/timing.

What are social interaction skills?

Skills used to maintain the flow of social interaction

What are client factors?

Internal capacities, characteristics, and body functions that influence occupational performance.

Examples of client factors?

Cognition, vision, sensation, pain, swelling, skin condition, values, beliefs, and spirituality.

What characteristics should OT goals have?

Timely, measurable, reimbursable, client-centered, and occupation-centered.

What is included in a Plan of Care (POC)?

What interventions will be provided and the frequency/duration of services.

What determines treatment frequency?

The practice setting and client needs.

What is adaptation?

Modifying the setting or task demands to facilitate performance.

What is compensation?

Using strategies or techniques to work around limitations.

What is habilitation?

Developing a new skill that did not previously exist.

What is maintenance?

Maintaining the client's current level of performance.

What is prevention?

Preventing the development of a disease or disorder.

What is rehabilitation (remediation)?

Regaining a lost or diminished skill.

examples of OT interventions?

ADL/IADL retraining, cognitive training, therapeutic activities, fall prevention, pain management, ergonomics, compensatory strategy training, and environmental modifications.

What is the typical flow of an OT treatment session?

Check-in → Determine plan → Execute plan → Debrief → Set new goals/confirm next session

What should be discussed during check-in?

Goal progress, health updates, medication changes, and client concerns

What is the main question asked during re-evaluation?

Did the client achieve their goals?

What happens if goals are not achieved?

Develop new goals/POC or discharge if appropriate.

What happens if goals are achieved?

Discharge or create new goals and continue treatment.

What are OTPF outcome categories?

Improvement, enhancement, occupational performance, prevention, health and wellness, quality of life, participation, role competence, well-being, and occupational justice.

What does CPT stand for?

Common Procedural Terminology.

What are CPT codes used for?

Billing for services provided.

what is the CPT codes billing based on?

tts dependent on the setting

What OT services commonly use CPT codes?

Evaluation, re-evaluation, and treatment

What must OT evaluations include according to CPT requirements?

Occupational profile, medical/therapy history, assessments, and plan of care.

Why is collaboration with other professionals important in evaluations?

It ensures care is coordinated according to client needs.

What three criteria determine OT evaluation complexity?

Profile & History, Assessment of Occupational Performance/Deficits, and Clinical Decision Making.

What are the three complexity levels?

Low, Moderate, and High

Low complexity profile/history requires what type of review?

Brief history review.

Moderate complexity profile/history requires what type of review?

Expanded review of records and history.

High complexity profile/history requires what type of review?

Extensive review of records and history.

Low complexity identifies how many performance deficits?

1-3 deficits.

Moderate complexity identifies how many performance deficits?

3-5 deficits

High complexity identifies how many performance deficits?

5 or more deficits.

What characterizes low-complexity clinical decision making?

Low analytic complexity, limited treatment options, and few/no modifications.

What characterizes moderate-complexity clinical decision making?

Moderate analytic complexity and minimal to moderate modifications.

What characterizes high-complexity clinical decision making?

High analytic complexity and significant modifications/assistance needed.

What rule determines the final complexity level?

All three categories must meet the higher level to bill at that higher complexity.

If two categories are moderate and one is high, what is the overall complexity?

Moderate.

If two categories are high and one is low, what is the overall complexity?

Low.

What is the most important complexity rule to remember?

The overall rating defaults to the lowest level present among the three categories.

CPT code for low-complexity OT evaluation?

97165.

CPT code for moderate-complexity OT evaluation?

97166

CPT code for high-complexity OT evaluation?

97167