Fieldwork Chapters 1 & 2

CHAPTER 1

  • four principles to guide OT practice

    • client centered practice

    • occupation centered practice

    • evidence based practice

    • culturally relevant practice

  • OTPF

    • domain: outlines and identifies area where OTs have knowledge and expertise, outlines the purpose of OT practice

      • occupations

      • contexts: refers to environmental and personal factors influencing occupational performance

      • performance patterns: habits, routines, roles, rituals, can support or hinder occupational performance

      • performance skills: motor skills, process skills, social skills

      • client factors: includes values, beliefs, spirituality

    • process: delivery of OT services, emphasizing client centered and occupation based practices

      • evaluation

        • occupational profile: summarizes info related to client’s occupational history, experiences, interests, values, needs, reasons for seeking services, etc

        • analysis of occupational performance: identifies client’s assets, limits, potential hinderances or barriers

        • synthesis: interpretation of information gathered to determine priorities for intervention and outcomes, working with client to create goals

      • intervention

        • intervention plan: integration of information from evaluation with theory, practice models, FoRs, and research to develop action plan

        • intervention implementation: implementation of action plan and continuous monitoring of client’s response to intervention

        • intervention review: reviews effectiveness of intervention plan and client’s progress towards goals and outcomes

      • outcomes

        • selecting outcome measures: OT selects valid, reliable measures for targeted outcomes

        • measuring progress and adjusting goals and interventions: monitoring progress, updating goals, modifying intervention and creating plan for transition or discontinuation of OT services

  • official documents

    • undergo review every 5 years

    • ACOTE: accreditation council for occupational therapy education, provides accreditation standards for educational programs

CHAPTER 2

  • health record: compilation of data that includes the client’s past and present health information

    • purpose is to serve as medical and legal documentation of client’s history, current condition and status, and any interventions

    • continuously going through changes

    • contain administrative information

      • demographic information

      • payment source

      • account number

      • patient ID number

      • consent to release information

  • history of health records

    • can be traced back to cave paintings

    • electronic health records began in 1960s

      • electronic medical records (EMRs) contain medical and treatment information for a patient at a single location

      • electronic health records (EHRs) focus on total health of patient going beyond clinical data; designed to share information across many providers and locations

    • printed health records

      • source oriented: grouped together by the source they came from

      • integrated: documents from various sources entered in reverse/chronological order

      • problem oriented: documents organized according to client’s problem list

        • basis for SOAP note format

  • history of SOAP note

    • Subjective: includes client’s report of their problems, limitations, needs as well as client’s POV of treatment and progress

      • typically brief (exception: initial eval)

    • Objective: health professional’s observations of client’s performance and treatment provided

      • includes all measurable, quantifiable and observable data

    • Assessment: contains health professional’s analysis and interpretation of events reported in S and O sections

      • shows practitioner’s professional reasoning

    • Plan: plan of what to do next, includes anticipated frequency and duration of services

      • includes detailed intervention plan

    • SOAP notes are not the only outline for organizing information

  • purposes of client care documentation

    • client care management

      • how treatment team communicates with each other about client’s care

      • good documentation important for ensuring continuity of care within and between settings

    • reimbursement

      • source for what services were provided and what may be billed

      • insurance may review documentation to determine if services are worth paying for

      • utilization review: review of health record that occurs after the services have been provided; safeguards against unnecessary and inappropriate medical care

      • utilization management: proactive processes that take place before and during a client’s provision of health services

        • ensures health care continuously deliver appropriate levels of care

    • legal system

      • part of legal documents

      • if called to appear in court, having documentation that is accurate, clear and thorough is important

    • quality improvement

      • framework for improving quality of health care delivery by measuring and analyzing various processes within a healthcare system

      • health record is primary source of information used in quality improvement process

    • accreditation

    • education and research

      • provide data for research

      • identify and document the incidence of certain medical conditions

    • business development and management

      • provide productivity measure of OT practitioner workload and performance

        • measure of the amount of billable time in a practitioner’s workday

    • client access

      • improve client’s sense of control over their health and wellbeing

      • US is encouraging clients to use a personal health record (PHR)

        • maintained and controlled by the client

    • advocacy

      • documentation can help with advocating for a client

      • helps advocate for the importance of the OT profession