| Documentation |
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| IFSP |
Individualized family service plan |
document required in early intervention programs |
legally binding document outlining all service provisions |
goals are established yearly |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| Soap note |
subjective |
objective |
assessment |
plan |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| documents used by |
treatment team |
chart reviewer for quality assurance |
third part payer |
legal system |
acrediting agencies |
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| 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) |
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mr. charles11
