DOCU - 5

What is the purpose of the Evaluation Report in Occupational Therapy?

• To summarize intervention and client's progress toward the goals

• To identify frequency and duration of service, service provider, and location of service

• To provide information on referral source and data gathered during evaluation process

• To provide client's occupational profile, analysis of client's occupational performance, and expected outcomes of intervention

What type of information does the Intervention Plan document contain?

• Date, length of time, and interventions

• Client's goals and approaches used to reach those goals

• Client's progression from one type of setting to another within the same delivery system

• Specific interactions between client and OT practitioner

What does the Progress Notes / Report summarize?

• Client's progression from one type of setting to another within the same delivery system

• Client's current status and reason for transition

• Changes to services, goals, frequency

• Intervention and client's progress toward the goals

What does the Discharge / Discontinuation Report document?

• Specific interactions between client and OT practitioner

• Client's goals and approaches used to reach those goals

• Summarizes changes in client's ability to participate in occupations between initial evaluation and discontinuation of services

• Frequency and duration of service, service provider, and location of service

What is included in the Service Contact documentation?

• Client's goals and approaches used to reach those goals

• Date, length of time, and interventions

• Client's current status and reason for transition

• Summarizes changes in client's ability to participate in occupations between initial evaluation and discontinuation of services

What does the Transition Plan provide information regarding?

• Changes to services, goals, frequency

• Client's current status and reason for transition

• Client's goals and approaches used to reach those goals

• Frequency and duration of service, service provider, and location of service

What does the Occupational Therapy Process include?

• Client Identification, Screening, and Initial Evaluation

• Intervention Planning, Intervention, and Re-evaluation

• Discontinuation, Follow-up, and Evaluation Report

• Service Contact, Progress Notes, and Transition Plan

What is the purpose of the Follow-up Note in Occupational Therapy?

• To provide client's occupational profile, analysis of client's occupational performance, and expected outcomes of intervention

• To summarize intervention and client's progress toward the goals

• To provide recommendations for changes to services, goals, frequency

• To provide recommendations and rationale for OT services, modifications or assistive technology

What does the Client Identification documentation include?

• Screening Report and Contact Note

• Attendance Logs and Progress Flow Sheets

• Evaluation Report / Evaluation Summary and Intervention Plan

• Referral or Physician's Order and Contact Note

What is the purpose of the Screening Report in Occupational Therapy?

• To provide client's occupational profile, analysis of client's occupational performance, and expected outcomes of intervention

• To summarize intervention and client's progress toward the goals

• To identify frequency and duration of service, service provider, and location of service

• To provide information on referral source and data gathered during evaluation process