Documentation for the OTA

Documentation for the OTA

• Documentation is very important.
• Writing in the health record is crucial.
• Accurate record keeping is essential.
• Documentation provides feedback to the OT and treatment team.
• Documentation is a skill that requires practice.

SOAP Note Format

• SOAP note format includes:
  • S - Subjective
  • O - Objective
  • A - Assessment
  • P - Plan

Requirements for Documentation

• Documentation is required to meet strict standards.
  • Reimbursement depends on proper documentation.
• You will see a variety of styles among OT practitioners.
• Must comply with accepted legal and facility standards.
• ICF (International Classification of Functioning, Disability and Health) provides a common language.
  • Common language for information sharing and international policy planning that consists of descriptions of all aspects of human function and disabilities.
  • Includes:
    • Body structures and function
    • Activities and Participation
• OTPF (Occupational Therapy Practice Framework)
  • Six domains

Occupational Profile

• Occupational Profile: a client-centered approach to gathering information.
  • Allows clinician to determine any contextual or environmental features, activity demands, or individual client factors that need to be addressed.
  • Includes:
    • Occupational history
    • Interests
    • Experiences
    • Habits
    • Patterns of daily living
    • Client values and needs
    • Client hopes to gain from present situation
  • Allows client to set priorities for treatment.

Process of Service Delivery

• Occupational Profile:
  • 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.
  • The client’s 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

• Intervention Plan:
  • A plan that will guide actions taken and that is developed in collaboration with the client.
  • It is based on selected theories, FOR (Frames of Reference), 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.
  • Client’s response is monitored and documented.
• Intervention Review:
  • Review of the implementation plan and process, as well as its progress toward targeted outcomes.
  • Supporting health and participation in life through engagement in occupation.
• Outcomes:
  • Determination of success in reaching desired outcomes.
  • Outcome assessment information is used to plan future actions.

Influencing Contexts and Environments

• Internal
• External
• Physical
• Social
• Virtual
• Activity Demands: Interactive
• Are skills you teaching transferable?
• Documentation should always include contextual and environmental issues or problems with appropriate intervention follow-up.

Underlying Factors

• Client Factors
  • Body structures
    • Provide base of stability for body systems to function.
    • Some problems can be fixed temporarily/permanently.
  • Body functions
    • Body systems perform their duties.
    • Vital processes of basic life and movement.

Performance Skills

• Performance skills
  • Client behaviors and actions grouped into five areas:
    • Emotional regulation
    • Motor and praxis
    • Cognitive
    • Sensory-perceptual
    • Communication and social
  • Observe and analyze performance skills, document how task is performed and what factors may impede function. You will be documenting your professional observations and analysis of behaviors, actions, skills and underlying factors in SOAP note.
• Documenting OT services focuses on the ability to engage in occupation; this is important to demonstrate the necessity for OT and for preventing any questions of duplication of services.
• Each funding source has specific guidelines for what services they allow or consider necessary and will reimburse.
  • Type of interventions
  • Frequency/duration
  • Special equipment
• Eight areas of occupation
  • ADL (Activities of Daily Living)
  • IADL (Instrumental Activities of Daily Living)
  • Work
  • Leisure
  • Play
  • Education
  • Social Participation
  • Rest and Sleep

Roles of the OT and OTA

• Different roles and responsibilities in documenting the OT intervention process.
  • OTA partners with OT in designing, implementing, and assessing OT services.
  • As OT professionals are responsible and accountable for adhering to the mandatory policies and procedures adopted by state and federal regulatory agencies regarding documentation.

Type of Notes

• Different notes at different stages of the OT process.
• Vary according to the practice setting.
• From the first notation of referral to the closing line of discharge - we document.
• Specific content of note, format and organization of the note, the timelines required all vary.
  • Initial Evaluation Reports - Before beginning treatment 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 specified period of time. Record progress toward goals and details any changes in intervention plan.
  • Reevaluation Report - Many reasons: 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 treatment 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 of AE/DME (adaptive equipment/durable medical equipment), splints, HEP (home exercise program).
• Professional documentation pulls together all of your observation skills, clinical reasoning and knowledge of occupational therapy.