documentation oth2261 exam 1

  1. documentation
    documentation of treatment justifies the therapy

    it is the written record of all information relevant about the client from admission to discharge
  2. the written record should include:
    1.confirmation of the referral

    2.initial evaluation results

    • 3.ongoing weekly/daily progress notes which:
    • -treatment goals
    • -methods and modalities used
    • -functional outcomes
  3. purpose of documentation:
    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
  4. documentation and ethics
    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
  5. ethical practice:  confidentiality
    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)
  6. legal aspects of documentation
    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
  7. health records may examine by:
    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
  8. HIPAA-health insurance portability & accountability act
    law covers many topics including: of american workers regarding health insurance 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: the health information will be used

    2.what will be disclosed the client can get access to this information
  9. HIPPA privacy notice
    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

  10. HIPPA requires:
    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
  11. FERPA & IDEA-1997 revision
    family education rights & privacy act of 1974
    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


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

    2.IFSP-individual family service plan (0-2 age)
  12. IDEA-individuals with disabilities education act
    • specifically defines identifying information as:
    • of the child, parent, or other family member

    2.address of the child security number

    4.list of characteristic or other information that would result in reasonable certainty of the identity of the child
  13. Legal aspects of documentation
    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"
  14. documentation of OT services
    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
  15. documentation guidelines 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 not criticize another health care provider in the written record

    6.avoid negative statements toward the client not change a legal record after the fact without clarifying the time and nature of the change
  16. mechanics of documentation
    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 concise

    6.use appropriate terminology

    7.use only the abbreviations that are approved by your facility
  17. responsibility
    the OTR has ultimate responsibility for all documentation

    the COTA has complete responsibility for preparation of certain reports
  18. the OTA contributes to:
    • 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 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
  19. fundamental elements of documentation
    1.patient/client's full name and case number on each page 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 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
  20. automated documentation systems
    therapy documentation software systems:

    1.basic documentation


    3.administrative tracking

    4.outcome data


    1.time saver

    2.collating data for outcome studies

    3.more advanced

    4.more accurate


    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
  21. POMR
    problem oriented medical record
    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 base

    2.a problem list

    3.treatment plan

    4.SOAP or progress notes
  22. SOAP note
    used for communicating daily or weekly information within facilities

    data base includes:



    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
  23. s-subjective
    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
  24. O-objective
    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
  25. A-assessment
    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
  26. P  plan
    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
  27. progress notes
    • may be required:
    • per treatment



    • Many formats:
    • narrative
    • SOAP note
    • problem-focused note
  28. daily note
    generally brief

    • reflect the:
    • client response to treatment
    • treatment provided
    • progress noted
    • revision of treatment plan and goals is not always necessary
  29. weekly note
    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
  30. guidelines for note writing
    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 brief

    16.ensure your notes will be read
  31. rules and guidelines that apply to notes:
    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


    7.typewritten or printed if necessary

    8.correct grammar and spelling are mandatory 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
  32. initial note
    record that the OTR and COTA have received and acted on the referral for service

    • includes:
    • 1.source of referral

    2.reason for referral the referral was received

    4.plan for further contact

    the COTA may be asked to write the initial note
  33. evaluation reports
    • 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
  34. the COTA does not:
    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
  35. treatment plans

    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
  36. 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
  37. treatment plan-objectives
    • behaviorial objective
    • -an objective or goal written in clear, specific, and measurable terms

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

    2.condition statement


    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
  38. evaluate the objective(of the treatment plan):
    • 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
  39. treatment-levels of assistance
    • 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
  40. re-evaluation report

    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
  41. discharge or discontinuation report

    • 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


    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
Card Set
documentation oth2261 exam 1
documentation oth2261 exam 1