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OT Documentation
Documentation
| Documentation | 1 | 2 | 3 | 4 | 5 | 6 |
|---|---|---|---|---|---|---|
| IFSP | Individualized family service plan | document required in early intervention programs | legally binding document outlining all service provisions | goals are established yearly | (blank) | (blank) |
| IEP | Individualized Educational Program | documented program for ages 3-21 who recieve specil services in public school | establishes LTG for three years which are reviewed anually and revised in STG | STG are usually for one year | (blank) | (blank) |
| ITP | Individualized transition program | requirement of the IDEA it is a special version of the IEP for children starting no later than age 14 or 16 fo all children in special education | set activities for student to promote transition from school to post school | (blank) | (blank) | (blank) |
| IHP | individualized habilitation plan | variation of the ifsp or iep for children placed in mental retardatiion or developmental disabilities program | used in the day training setting | (blank) | (blank) | (blank) |
| MDS | minimum data set | used in nursing homes | consists of a core set of screening and assessment elements | part of the Residential Assessment Protocol | the Basic asessmenty tracking form part is completed yearly | (blank) |
| Quality Assurance | a system of review used to ensure the quality of the work being preformed in health care | the plan of qa is usuall Continuous Quality Improvement | Utalization Review - reviews the use of resources within the facility | (blank) | (blank) | (blank) |
| Documentation- | communicating information about the client to others | sequential record of services provided and condition of client throughout the course of treatment | serves legal, financial, and care continuity purposes | shows that treatment is related to the goals of the treatment plan | (blank) | (blank) |
| Key elements of documentation | demographics of client and details of ot service | name, diagnosis, referral, place of service, date, time, name of caregiver and provider info | (blank) | (blank) | (blank) | (blank) |
| organization of records | source oriented-can see what ot has been doing , but don't have overal picture | problem oriented- set of treatment related to each problem, makes it hard for one disciplin to track their own sequence | integrated- everything is in chronological order- may not be able to track changes over time and in relationship to particular goal | (blank) | (blank) | (blank) |
| Soap note | subjective | objective | assessment | plan | (blank) | (blank) |
| Goals | statements of the desired functional acheivement that are anticipated as a result of the intervention plan | purpose of goal is to develop a functional skill not the component skill | Terminal Behavior- the expected, performance area observable behavior (sometimes called outcome) | conditions- the circumstances in which the terminal beahvior will be observed (sometimes it is the setup) | STG sometimes called objectives | (blank) |
| criterion for measurement | refers to level of proficiency or degree of competence with which the task will be preformed | one ex is frequency- number of times desired task will occure in order to be considered achieved | (blank) | (blank) | (blank) | (blank) |
| Purpose of goals | Habilitative- used with skills that were not previously present ( always with genetic/congenital disorders) | Rehabilitative- (restorative-seek to accomplish skills through reduction of performance component deficit affecting skill achievment)(Modification- may be achived through the use of compensatory or adaptive methods | goals for health promotion/wellness or disease/disability prevention( used when there is a likelyhood that skills will deteriorate over time | can use goal as management tool (child nursing home) | instructive or teaching goals-related to the process of giving care to the child | (blank) |
| groups that set standards for the documentation | JCAHO- Joint Commission on Accreditations of Health care Organizations | CARF Comission on Accreditation of Rehabilitation Facilities | CORF Comprehensive Rehabilitation Outpatient Services | Medicaid | Third party insurers | (blank) |
| documents used by | treatment team | chart reviewer for quality assurance | third part payer | legal system | acrediting agencies | (blank) |
| STG from LTG | 1. break LTG into steps to achieve LTG (STG= grading by steps) | Change some aspects of the condition or criterion of the LTG for the STG ( assistance/ time/ etc) | (blank) | (blank) | (blank) | (blank) |
Created by:
natkat
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