Documentation types & guidelines

What is the purpose of documentation

communicates a person’s occupational hx and experience, provides a justification for services, articulate OT services given and why they were chosen, chronological or running record of client status, OT services provided to the client, client’s response and outcomes

documentation things to consider

complete, concise, accurate, timely, legible & clear, grammatically correct, & objective (all in a maintained professional legal manner)

Fundamentals need in documentation

client’s identifying information (DOB, Gender, Full Name, Case # [sometimes]), Identify document type & date of service, acceptable use of professional terms & abbreviations, signature & credentials

abbreviations

must be acceptable for all readers to understand

reliability stats

explain professional jargon

separate facts from professional judgement

correct terms to represent client

professional signature & credentials

directly after note is written

OT, OTA, OTS signature w/ credentials → co-signature when necessary & appropriate → payer policy, government laws & regulations, supervision, or employer requirements

in black or blue ink

Content

accurately, chronologically & honestly report results → eliminates personal judgement

synthesize → clear rationale for purpose, value & necessity for skilled OT service

grammar

past tense & active tense → changes in different sections

proof read

errors

cross out & initial & date → 1 line through the words

disposal &/or storage of documents must meet state/federal guidelines & meet confidentiality requirements

submit work timely

review others “deidentified” reports & practice →need to know bases

important when documenting

never base OT services on diagnosis or prognosis → IT’S based on functional impact from diagnosis

types of documentation

screening

evaluation/re-evaluation

intervention

outcomes

ex of screening documentation

screening report

ex of eval/re-eval documentation

eval report, re-eval report

ex of intervention document

intervention plan, contact report (daily note), progress report, transition plan

ex of outcomes documentation

discharge/discontinuation report

screening

reminder: NO hands on the client

determine the need for a full evaluation (referral from OT, physician, client, family)

screening process documentation key points

documents referral source & the reason for OT screening

consists of initial brief assessment to determine need for a OT eval or referral to another service

do not put hand on client

screening report (components)

referral info

client info

brief occupational profile

assessments

recommendations

screening report: referral info

reason for referral, referral source, services requested

screening report: client info

client’s occupational history, experience, & performance, health status, applicable medical, educational and developmental diagnosis, precautions and contraindications

screening report: brief occupational profile

why client seeking OT, what are successful at/what is problematic, medical, educational & work history, client priorities & targeted goals

screening report: assessments

interview, record review, observations

screening report: recommendations

professional judgement — is need for complete OT eval

evaluation report

documents referral source & data gathered through the OT eval process

eval/reeval process report documentation key points

client info

occupational profile

assessments used

analyzed occupational performance

summary & analysis

recommendations

eval/reeval process report: assessments used

standardized/non-stand, interviews, record reviews, ect.

eval/reeval process report: analysis of occupational performance

identify factors that support of hinder client’s performance → their skills, patterns, contexts, activity demands, outcomes, ect.

eval/reeval process report: summary & analysis

interpretation of the occupational profile and occupational performance issues, identification of targeted areas of occupation and occupational performance to be addressed along with expected outcomes

eval/reeval process report: recommendation

judgement regarding the necessity for skilled OT services, are other services needed instead or in combination with OT

private insurance requirements for OT eval

AMA → American Medical Association requires you to determine CPT codes based on

1. level of complexity (low, moderate, high)

2. CPT codes are identified by 3 parts of the OT eval

   1. occupational profile, medical & therapy history

   2. assessments of occupational performance

   3. clinical decision making

Medicare & Medicaid requirements for OT eval

Use GG code looking at self-care and functional skills

used to uniformly document performance @ admission

scoring criteria is on a 6-1 scale (6 = independent & 1 = dependent)

formal re-eval conducted when

new clinical findings occur

significant change in clients condition, furthering testing

client demonstrates response to plan of care

additional info required for discharge

required guidelines for federal or state info

what does the re-eval report still have

client info

occupational profile

re-eval results

analysis of occupational performance

summary & analysis

recommendations

re-eval report still have: occupational profile

any updates on current areas of occupation that are successful, problematic, summary of any new information, updates on changes

re-eval report still have: analysis of occupational performance

factors that support or hinder performance

re-eval report still have: summary & analysis

compare data from referring concern (evaluation data) to present day data- There is a CPT code that is used to identify a re-eval. For clients who have Medicare and Medicaid, the scoring GG codes should be redone

re-eval report still have: recommendations

changes to OT services, revisions to goals, changes to frequency of services, and further recommendations, etc.

Intervention process types of reports

intervention plan, daily notes, progress notes, transition plan

Intervention plan/plan of care documents the

goals, intervention approaches, types of interventions used in the OT process on the basis of data gathered form results of the eval & re-eval to achieve client outcomes, referrals to other services, pain levels, time spent on modalities, ect.

Intervention plan/plan of care components

client info

intervention goals

intervention approaches & intervention types

service delivery mechanisms

plan for discharge

outcomes measures

(sometimes) physician certification of intervention plans and plan of care

Intervention plan/plan of care component: client info

precautions & contraindications

Intervention plan/plan of care component: intervention goals

measurable & meaningful occupation based long & short terms directly related to client’s need to participate in occupations.

(Need to be based on eval/re-eval results and adhere to each payer’s sources documentation requirements.)

Intervention plan/plan of care component: service delivery mechanisms

the provider, the location, frequency & duration of services

Intervention plan/plan of care component: plan for discharge

Discontinuation criteria

Intervention plan/plan of care component: outcomes measures

Tools that assess occupational performance

Intervention plan/plan of care component: who might require a Physician certification of intervention plans and plans of care

state practice acts and third-party payers including Medicare & Medicaid

Contact Report (daily treatment notes)

Documents contacts between client & OTP. Record intervention types,
goal progress, client's response, and intervention approaches used in the
OT process

Contact Report (daily treatment notes) components

client info

therapy log → SOAP note or DAP note

Progress report

Documents a summary of the intervention process; goals, types, approaches used, documents achievement toward client goals, includes any new data or changes to service frequency, need for continued service and or discontinuation.

(Medicare & Medicaid want a progress report every 10 treatment days!!!!)

Progress report components

client info

summary of serviced provided

current client performance

plan/recommendations

transition plan

A documented formal plan when a client is transitioning from one service/setting to another within a service delivery system

Transition plan comonents

client info

client’s current status

transition plan

recommendations

discharge/discontinuation report

The plan written to support the client’s discharge from OT services.
Summarizes the changes in the client’s ability to engage in occupations between the initial evaluation and the discontinuation of services.

discharge/discontinuation report components

client info

summary of the intervention process

recommendations

discharge/discontinuation report component: summary of the intervention process

date of initial & final service, # of sessions, summary of interventions used, summary of goal progress, OT outcomes, initial client status and ending client status in regard to engagement in occupations.

what does Medicare & Medicaid need in the summary of intervention used for a discharge/discontinuation report

their corresponding scoring of the GG codes completed again