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Documenting OT

Fundamentals Test 1 (stack 3)

QuestionAnswer
Documentation is often the determinate in the reimbursement of services; reflects clinical reasoning and judgement
Client Records confidential; legal documents; can be subpoenaed for court
Types of Documentation Initial & Re-evaluation Report
IE Initial Evaluation; completed by OTR; includes client info;referral;identified areas of dysfunction
IE includes the description and judgement about performance skills, patterns, context and environments, client factors impacting performance; recommendations regarding continuation or dc plans
Re-evaluation includes updates of dysfunction, summary of any new information, changes in status and outcomes
Re-evaluation recommendations for changes in services, revision or continuation of goals, frequency, recommendation to other professionals/agencies
Contact Note documents contact between client and OT practitioner; records types of interventions used and the clients response
Contact Note Reason a session was missed or cancelled
PN Progress notes are written on a scheduled basis; summary of the intervention; completed by OTR/COTA
PN include client info, frequency, strategies, modifications, AE, orthotics provided, education provided and DME recommended
Transition Plan written when client is transitioning from one setting to another
Transition Plan recommendations for modifications or accommodations, assistive tech devices and environmental modifications
IEP Individualized educational program
IEP guides services for ages 3-21; includes special education and related services; written every year and reviewed every 6 months
IEP present level of education, goals, measurement of progress
S.O.A.P subjective, objective, assessment and plan
Subjective includes information or statements the patient/family/caregiver share in relation to their problems, limits, needs, progress and feelings
Objective includes observable, measurable, quantifiable data obtained during the OT session
Objective results of assessments, what you did (interventions provided), what was observed, client responses/functional status
Assessment consists of the clinicians skilled appraisal of the client
Plan What you plan to do? What needs are you addressing? What recommendations you may plan to make and Frequency and duration
Created by: Terrie2014