Documentation

• OT documentation services

  All information recorded about the patient from the time of referral to the time of discharge from OT
• OT documentation

  • It consists of written records and reports that contain pertinent information about the patient's status, progress, and performance
  • It is part of the legal record
  • Omission or errors may cause doubts about the accuracy of the entire record
• Clinical Documentation


  Provides a chronological record of the client's status and condition related to occupational functioning and details the course of therapeutic intervention

  
• Practitioners document OT services abiding by the time frames, format, and standards established by the practice settings, government agencies, external accreditation programs, and payers
• Initial OT screening

  1. Documents referral source, reason for OT screening, and need for OT evaluation and service

  2. Consists of an initial brief assessment to determine client's need for an OT evaluation or for referral to another service if not appropriate for OT services
• Suggested content for initial OT screening

  • Client information (Name/agency; date of birth; gender; health status; and applicable medical/educational/developmental diagnoses, precautions, and contraindications)
  • Referral information (Date and source of referral, services requested, reason for referral, funding source, and anticipated length of service)
  • Brief occupational profile (reason for seeking OT services, current occupations that are successful and problematic, contexts and environments that support and hinder occupations, medical/educational/work)
  • Assessments used and results (Types of assessments used and results (e.g. interviews, record reviews, observations))
  • Recommendation (Professional judgments regarding appropriateness of need for complete OT evaluation)
• OT Evaluation

  1. Documents referral source and data gathered through the evaluation process in accordance to guidelines

  2. Includes: Analysis of occupational performance and identification of factors that support and hinder performance and participation; and Identification of specific areas of occupation and occupational performance to be addressed, interventions, and expected outcomes
• Suggested content for OT Evaluation

  • Client information—Name; date of birth; gender; health status; medical history; and applicable medical/educational/developmental diagnoses, precautions, and contraindications
  • Referral information—Date and source of referral, services requested, reason for referral, funding source, and anticipated length of service
  • Occupational profile—Client's reason for seeking occupational therapy services, current areas of occupation that are successful and problematic, contexts and environments that support or hinder occupations, medical/educational/work history, occupational history (e.g., patterns of living, interest, values), client's priorities, and targeted outcomes
  • Assessments used and results—Types of assessments used and results (e.g., interviews, record reviews, observations, standardized and/or non standardized assessments)
  • Analysis of occupational performance—Description of and judgment about performance skills, performance patterns, contexts and environments, activity demands, outcomes from standardized measures and/or nonstandardized assessments, and client factors that will be targeted for intervention and outcomes expected
  • Summary and analysis—Interpretation and summary of data as related to occupational profile and referring concern
  • Recommendation—Judgment regarding appropriateness of OT services or other services
• OT Reevaluation

  1. Documents the results of the reevaluation process

  2. Frequency of reevaluation depends on the needs of the setting, the progress of the client, and client changes
• Suggested content for OT Reevaluation

  • Client information—Name; date of birth; gender; and applicable medical/educational/developmental diagnoses, precautions, and contraindications
  • Occupational profile—Updates on current areas of occupation that are successful and problematic, contexts and environments that support or hinder occupations, summary of any new medical/educational/work information, and updates or changes to client's priorities and targeted outcomes
  • Reevaluation results—Focus of reevaluation, specific types of outcome measures from standardized and/or nonstandardized assessments used, and client's performance and subjective responses
  • Analysis of occupational performance—Description of and judgment about performance skills, performance patterns, contexts and environments, activity demands, outcomes from standardized measures and/or nonstandardized assessments, and client factors that will be targeted for intervention and outcomes expected
  • Summary and analysis—Interpretation and summary of data as related to referring concern and comparison of results with previous evaluation results
  • Recommendations—Changes to occupational therapy services, revision or continuation of interventions, goals and objectives, frequency of occupational therapy services, and recommendation for referral to other professionals or agencies as applicable
• OT Intervention Plan

  1. Documents the goals, intervention approaches, and types of interventions to be used to achieve the client's identified targeted outcomes and is based on results of evaluation or reevaluation processes

  2. Includes recommendations or referrals to other professionals and agencies in adherence with each payer source documentation requirements (e.g., pain levels, time spent on each modality)
• OT Progress Notes

  1. Documents contacts between the client and the occupational therapy practitioner

  2. Records the types of interventions used and client's response, which can include telephone contacts, interventions, and meetings with others

  3. Summarizes intervention process and documents client's progress toward achievement of goals, including new data collected, modifications of treatment plan, and statement of need for continuation, discontinuation, or referral

  
• OT Discharge Report

  1. Documents the formal transition plan and is written when client is transitioning from one service setting to another within a service delivery system

  2. Summarizes the changes in client's ability to engage in occupations between the initial evaluation and discontinuation of services and makes recommendations as applicable
• Suggested content for OT Discharge Report

  • Client information—Name; date of birth; gender; and diagnosis, precautions, and contraindications
  • Summary of intervention process—Date of initial and final service; frequency, number of sessions, and summary of interventions used; summary of progress toward goals; and occupational therapy outcomes—initial client status and ending status regarding engagement in occupations, client's assessment of efficacy of occupational therapy services, and comparison of pre- and postintervention standardized and/or nonstandardized outcome measures used
  • Recommendations—Recommendations pertaining to the client's future needs; specific follow-up plans, if applicable; and referrals to other professionals and agencies, if applicable

  
• Purposes of OT documentation

  • Communicating patient's status and response to treatment to the other health care team members
  • Promoting continuity of treatment when staff changes occur
  • Providing clear, objective data about the patient on which future treatment can be based
  • Providing justification to utilization reviewers for continued treatment
  • Ensuring payment by third-party payers for services
  • Complying with the law and aiding in litigation
  • Providing a method to ensure patient rights and advocacy
  • Interpreting the treatment program to the patient's family, and other concerned individuals or agencies
  • Evaluating the effectiveness of OT intervention
  • Ensuring facility accreditation from such organizations
  • Providing data for research and advancement of the profession of occupational therapy
  • Facilitating training and student education programs
• SOAP note

  A format used in the Problem Oriented Medical Record (POMR), established by Lawrence Weed in the 1960s, that forces the writer to look into 4 sections: Subjective, Objective, Assessment, and Plan
• Subjective


  The patient's perception of the treatment being received, the progress, limitations, needs, and problems
• The subjective note is brief, however in the initial evaluation note it might be longer since it will contain the information OT obtained in her interview
• Subjective data


  Information that cannot be verified or measured during the treatment session, such as the patient's report of limitations, concerns, problems (e.g. pain, fatigue), expressions of feeling, attitudes, goals, and plan
• Common errors in writing subjective notes include not making effective use of good communication time and not listening effectively
• Good practice in writing subjective notes includes using therapy time effectively and not for social talk, and writing concisely and coherently
• Examples of subjective statements


  • "I can't feel anything with my hands"
  • "I'm wobbly as all get out today"
  • Pt. expressed dizziness after bending down to touch the floor while in a seated position
  • Pt. acknowledged improvement in his sitting balance in comparison to the previous week
• Objective data contains all the measurable, quantifiable, and observable data from treatment sessions
• In the initial assessment, the "Subjective" and "Objective" sections make up the database from which the OT will develop a problem list and treatment plan
• Writing the Objective section

  1. Begin with a statement about the setting and purpose of the activity

  2. Follow the opening sentence with a chronological rendition of the session

  3. Information can also be organized into categories such as area of occupation-ADL and occupational performance skill
• When writing the Objective section, the focus should be on performance elements rather than the treatment media, the point of view should be from the OT's perspective rather than the patient's, and it should be clear that skilled OT was provided rather than just passive observation
• When writing the Objective section, be specific about the level of assistance provided, focus on the patient's response rather than what the OT did, and avoid being judgmental
• When writing the Objective section, focus on function, use only standard abbreviations, provide complete data in a concise format, and be professional and concise in wording
• Assessment


  The health professional's interpretation of the meaning of the events reported in the Objective section
• In the initial evaluation, the Assessment includes the patient's functional limitations and the OT's expectations of the patient's ability to benefit from therapy (rehabilitation potential)
• In the progress note, the Assessment contains statements regarding the patient's progress or lack of progress in therapy, which is the heart of the OT's clinical reasoning and shows the best impression to the reader

  
• Writing the Assessment

  1. Analyze the data in the Objective section

  2. Identify problems, progress, and rehabilitation potential

  3. Assess how the data impacts the patient's occupational performance

  4. End the Assessment with a statement that the patient would benefit from continued skilled occupational therapy, which justifies the plan

  
• Plan


  What the health professional plans to do next to continue with the goals and objectives in the treatment plan
• In the initial evaluation, the Plan contains the treatment plan along with the anticipated frequency and duration of treatment
• In the progress note, the Plan includes the specific treatment that will be provided next to achieve the stated goals
• Writing the Plan


  1. Consider what you would expect the patient to be able to do in the next week or two

  2. Specify the frequency and duration of treatment

  3. Identify the specific performance areas that will be addressed during that time

  4. End with a long-term or short-term goal, whichever is more appropriate for the patient and the practice setting
• The OT report should be signed and dated
• BFIP format


  A structured format for OT reports that includes Bi-Background Information, F-Findings, I-Interpretation, and P-Plan
• Suggested content for the Bi-Background Information section

  • Client's personal data
  • Diagnosis
  • Precautions/contraindications
  • Reason for referral
  • Therapist name
• Suggested content for the F-Findings section

  • Occupational Profile
  • Occupational Analysis/Analysis of occupational performance