Save
Busy. Please wait.
Log in with Clever
or
show password
Forgot Password?
Don't have an account?  Sign up 
Sign up using Clever
or
Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account. Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
focusNode
Didn't know it?
click below
 
Knew it?
click below
Don't Know
Remaining cards (0)
Know
0:00
edit
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

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
Popular Occupational Therapy sets

 

 



Voices

Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
Retries:
restart all cards