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OT Documentation


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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