documentation oth2261 exam 1

documentation of treatment justifies the therapy

it is the written record of all information relevant about the client from admission to discharge

1.confirmation of the referral

2.initial evaluation results

• 3.ongoing weekly/daily progress notes which:
• -treatment goals
• -methods and modalities used
• -functional outcomes

1.provide a sequential and legal record of the client's status and the course of treatment

2.provide information about the client's care

3.facilitate communciation among health care practitioners involved in the client's care

4.reflect the practitioner's reasoning

5.justify the need for continuing treatment

6.provide data for use in treatment, reimbursement, education, and research

documentation effectively communicates a client's response to therapy and educates other health care providers and fiscal intermediaries about the value of occupational therapy

unethical, incompetent or fraudulent documentation places the COTA at risk for legal repercussions and jeopardizes the credibility of the entire profession

no privileged information, verbal or written, can be released without the client's written constent

• AOTA code of ethics:
• principle #3:  occupational therapy personnel shall respect the recipient and/or their surrogate as well as the recipient's rights (autonomy, privacy, confidentiality)

must know the laws that effect practice and documentation

accrediting bodies

JCAHO(joint commission on accreditation of health care organizations)

CARF(commission on accreditation of rehabilitation facilities)

CORF(comprehensive outpatient rehabilitation facilities)

medicare, medicaid, third party payers

licensure, certification, registration

third party payers

fiscal intermediaries

utilization review boards-internal

the client has the right to know what is in the record and can ask for the information

must be provided according to facility policy

law covers many topics including:

1.protection of american workers regarding health insurance

2.protection of privacy rights of individuals


law was enacted in 1996, but the privacy section did not take effect until 2003

clients mustsign a form stating they have been informed of their rights, specifically:

1.how the health information will be used

2.what will be disclosed

3.how the client can get access to this information

must be written in plain language

required topics:

1.header with specific language

2.uses and disclosures

3.separate statements for certain uses and disclosures

4.covered entity's duties

5.complaint

6.contact

1.copies of documentation are not left on the therapist's desks where other can see them

2.clients charts/recoreds should not be left where any identifiable information is exposed to public view

3.documentation is not left on computer screens when a therapist steps away for the desk

4.all computers should be password protected

5.OT practitioners should not discuss clients in public areas of the facility (hallways, cafeteria,elevators) where you can be overheard

FERPA-identifies the confidentiality requirements of student's educational record

includes material written by school employees and contractors

covers all documents that contain the student's name, address, phone #, and other identifying information

includes:

1.IEP-individual education program(2+ age)

2.IFSP-individual family service plan (0-2 age)

• specifically defines identifying information as:
• 1.name of the child, parent, or other family member

2.address of the child

3.social security number

4.list of characteristic or other information that would result in reasonable certainty of the identity of the child

must accurately reflect the treatment given

documentation is the only acceptable proof of the treatment/intervention

"if it wasn't written, it did not happen"

1.initial notes

2.evaluation reports/assessment plans & notes

3.treatment/plans & goals

4.progress notes

5.treatment records

6.discharge summaries

7.consultation reports

8.special reports

9.critical incident reports & notes

1.date all entries for accurate sequencing of the treatment

2.document missed treatment

3.document at the time of treatment so that the entry will completely and accurately reflect the treatment session

4.document sepcific facts rather than general terms

5.do not criticize another health care provider in the written record

6.avoid negative statements toward the client

7.do not change a legal record after the fact without clarifying the time and nature of the change

1.always use waterproof black ink

2.never use correction fluid

3.correct errors

4.draw a line through the error, write your correction, initial and date the change

5.be concise

6.use appropriate terminology

7.use only the abbreviations that are approved by your facility

the OTR has ultimate responsibility for all documentation

the COTA has complete responsibility for preparation of certain reports

• 1.evaluation data
• -may perform certain screening and standardized assessments
• -based on service competency-perform task with same results as OTR

2.treatment plan

3.documentation of progress

4.reporting revisions in the treatment plan based on the reevaluation

5.the complete discharge summary in collabration with the OTR

6.co-signature may be required by the facilities accrediting bodies;third party payers;licenssure, certification, registration requirements

7.the COTA must be familiar with the documentation requirements of the facility, third-party payers and the state

1.patient/client's full name and case number on each page

2.date stated as month, day and year for each entry

3.identification of type of documentation and department name

4.practitioner's signature with a minimum of first name or initial, last name and professional designation

5.signature of recorder directly at the end of the note,without space left between the body of the note and the signature

6.co-signature of OTR on documenetation written by students and COTAs when required by law and/or facility

7.compliance with confidentiality standards

8.acceptable terminolgy as defined by the facility

9.facility approved abbreviations

10.errors corrected by drawing a single line through an error, (liquid correction fluid and erasures are not acceptable) and the correction initiated; or facility requirements followed

therapy documentation software systems:

1.basic documentation

2.billing

3.administrative tracking

4.outcome data

advantages:

1.time saver

2.collating data for outcome studies

3.more advanced

4.more accurate

disadvantages

1.difficult to design a system to meet all the needs of a program

2.cost of sufficient hardware to meet facility needs

3.cost of staff training

4.need of staff to accept the system

format used to structure documentation

encourages an interdisciplinary model

allows for adequate documentation required for quality assurance and third-party payers

4 sections of POMR

1.data base

2.a problem list

3.treatment plan

4.SOAP or progress notes

used for communicating daily or weekly information within facilities

data base includes:

physical

social

demographic information

contained in one report

from the data base a problem list is formulated and kept in front of the record

index to all  problems including anticipated problems

problems are numbered and named

• treatment plan:
• -titled and numbered according to the problem list
• -dated and signed

what has been said subjectively by the client or reported by significant others.(patients perception)

how he feels

his concerns

his beliefs

"the patient states....."

client's subjective comments about problems, complaints, life circumstances, goals, current performance, limitations, or other pertinent comments

with nonverbal clients-you can document nonverbal communication such as smiles, nods, and gestures

pain level-include

observable and measurable data derived from evaluation and treatment skills

repeatable evaluation findings

what the client does in treatment/what is done to him

data-vital signs, goni, mmt

statement of where and why the client was seen in OT

organized chronologically

objective data from tests

record the client's response to treatment but do not interpret the response

the opinion, interpretation or assessment of the results of the client's functional performance and anticipated outcomes

your interpretation, your opinion

if goal is in A, then it has been accomplished

prediction for progress

therapist's understanding of the client's problems

this is where you explain what all this data means

your professional judgement and skills come into play

problem list

the summary in "A" explains to the reader the correlations between the S, O, and P

justifies your recommendations

Drs. read A

the treatment plan,including long-term and short term goals

frequency and length of treatment

• what you plan to do to achieve your goals:
• -further treatment/new methods
• -consultation
• -modification to the previous plan

• may be required:
• per treatment

daily

weekly

• Many formats:
• narrative
• SOAP note
• problem-focused note

generally brief

• reflect the:
• client response to treatment
• treatment provided
• progress noted
• revision of treatment plan and goals is not always necessary

more thorough

summarize the:

1.treatment provided

2.the client's response to treatment

3.progress toward goals(or lack of progress with justification)

4.goals updated and treatment plan revised

stylistic advice:

1.record observation, not interpretations

2.let the reader draw his own conclusion based on fact

3.avoid judgemental language good job

4.undefined periods of time frequently, seldom

5.use measurable and defined periods

6.undefined quantities some, many

7.use numerical quantities

8.qualities hostile, bored

9.replace with actual observations-describe what the client is doing

10.failure to provide an objective basis for judgement "patient likes trains"  "patient stated he likes trains and will read anything on the subject"

11.give evidence to support statement

• 12.inappropriate use of clinical terminology
• -only a physician can diagnosis the patient "the patient was hallucinating"  "the patient appeared to be hallucinating; she was conversing when no one was there"

• 13.avoid jargon:
• -use terms that are understood by all staff
• -if used include a brief explanation

14.omit extraneous detail

15.be brief

16.ensure your notes will be read

1.the note should be organized in a logical fashion

2.similar ideas grouped together

3.each paragraph addresses a different area

4.should flow logically from the information that precedes it

5.notes need to be written neatly

6.legible

7.typewritten or printed if necessary

8.correct grammar and spelling are mandatory

9.be as brief as possible without omitting essential information or ideas

10.notes should be precise and factual

11.objective and truthful info

12.avoid vague generalizations or interpretations

13.should be written within the deadline that apply to the facility

14.must be written by date due

record that the OTR and COTA have received and acted on the referral for service

• includes:
• 1.source of referral

2.reason for referral

3.date the referral was received

4.plan for further contact

the COTA may be asked to write the initial note

• includes:
• 1.tests and evaluations administered and the results

2.summary and analysis of the client's assests and deficits, based on evaluation results and other objective sources. medical history, other therapists, other family members

3.recommendations for occupational therapy services-what type of service

the COTA may perform various structured evaluations

1. compile and interpret the results of the evaluation

2.documentation of evaluation data, responsibility of OTR

3.may be shared with the COTA

4.facility specific

includes:

1.LTG & STG

2.methods to be used

3.descriptions of activities & treatment procedures

4.frequency and duration of RX

5.anticipated completion date

6.projected outcome, or end result of treatment

• 1.maintain function
• -assist to use whatever capabilities they have

• 2.rehabilitation
• -restore the abilities after the disease process has been medically treated
• -potential to change-learn new skills

• 3.prevention
• -aims to interfere before dysfunction occurs

• behaviorial objective
• -an objective or goal written in clear, specific, and measurable terms

• three basic components:
• 1.behavior-outcome statement

2.condition statement

3.criterion

who, what, when, where, and the OT intervention

the objective describes the functional outcome or expected performance after treatment

how well the task must be performed in order for the goal or objective to be accomplished

• Relevant:
• -is the goal meaningful to the client and reflects his potential

• Understand
• -clearly stated in language understood by pt. and treatment team

• Measurable
• -criterion for success in quantitative terms

• Behavioral
• -utilize behaviors that can be seen and measured

• Achievable
• -what the pt. must do to accomplish the goal

• independent
• -pt. requires no assistance or cueing in any situation and is trusted in all situations 100% of the time to do the task safely

• supervision
• -caregiver is not required to provide any hands-on guarding but may need to give verbal cues for safety 

• contact guard/standby
• -caregiver must provide hands-on contact guard to be within arms length for patient's safety

• minimum assistance
• -caregiver provides 25% physical and/or cueing assistance

• moderate assistance
• -caregiver assists patient with 50% of the task.  assistance can be physical and/or cueing

• maximum assistance
• -caregiver assists patient with 75% of the task.  assistance can be physical and/or cueing

• dependent
• -patient is unable to assist in any part of the task.  caregiver performs 100% of the task for patient physically and/or cognitively

includes:

1.tests and assessments administered and the results

2.comparative summary and analysis of previous evaluation finding

• 3.reestablishment of projected functional outcomes
• -anticipated level of performance with therapeutic intervention
• -statement of changes in previous established functional outcomes report. 

4.update of intervention or treatment plan

the COTA is able to write and/or contribute to the re-evaluation.  comparing performance

includes:

• 1.therapy progress
• -summary of intervention, client's responses, number of sessions

2.goal attainment

• 3.functional outcomes
• -comparison of status pre/post

• 4.home program
• -written program to be followed after discharge

5.follow-up plans

6.recommendations

7.referral(s) to other health care providers and community agencies

the COTA is able to write and/or contribute to the discharge summary/report