documentation ch 1 & 2

Why do we document in OT?

• accurate record keeping

• distinct value of OT

• information and feedback

• Legal reasons

Distinct value of OT is to improve health and life quality through facilitating engagement and participation in occupations

Why do we use SOAP notes?

• Allows services to be reimbursable from third party

• Not all practitioners and facilities use SOAP

• •       Learning the basics for composing a SOAP note will make it easier to adapt and apply observations to other methods or recording client care.

• •       Other documentation essentials: billing/ reimbursement, documentation of a skilled service, electronic documentation, grammar, and medical terminology.

What is an occupational profile?

• §  Occupational participation, health and well-being, occupational justice, quality of life, and role competence

• ·       A client centers approach that helps practitioners determine whether contextual or environmental features, activity demands, or individual client factors need to be addressed.

• ·       Allows for appropriate goal setting and interventions to be determined.

• §  Presents a client-centered process that focuses on enabling individuals to perform desired life activities and meaningful occupation. Broken up into several areas.

age, gender, culture, developmental stages and temporal aspects, socioeconomic status

home, school, work, climate, terrain

family, colleagues, church community, internet and activity demands.

Types of notes: Initial evaluation

• in managed care, a client may need a reevaluation to justify further treatment sessions

• documentation of what occurred during your session. Can include telephone conversations and meeting that occur with client/family/other professionals or service providers

• completed by the OT and varies setting to setting. An evaluation done in a hospital will look different than those that are completed in a mental health or school setting

• written at the end of a specified period of time

Types of notes: Contact notes

• written when transferring to another facility

• done at the conclusion of OT and includes course of treatment, progress towards goals, status at time of discharge and recommendation of any DME, adaptive devices, splints or home programs. Will also include referrals or follow up as needed.

• in managed care, a client may need a reevaluation to justify further treatment sessions

• documentation of what occurred during your session. Can include telephone conversations and meeting that occur with client/family/other professionals or service providers

types of notes: progress report

• written at the end of a specified period of time

• in managed care, a client may need a reevaluation to justify further treatment sessions

• written when transferring to another facility

• documentation of what occurred during your session. Can include telephone conversations and meeting that occur with client/family/other professionals or service providers