Documentation

Question	Answer
Documenation	* Done daily (often) * All healthcare professionals * SOAP format most common * Integral part of patient care process * Significant time spent documenting daily
Reasons to Document	* Legal * Communication * Reimbursement * Decisions regarding Discharge * Helps organize therapist thoughts * Use for Quality Assurance * Research
Medical Record & Notes	* Legal Document can be subpoenaed * Never record false info, exaggerate, or make up data * Note about Patient NOT therapist * Concise, use of abbreviations, legible, clear, not vague
Medical Record & Notes continued...	* Don't use hyphen except with ROM * Semicolon and colon OK * No blank lines between entry * Sign all notes with full name and initials * No "white out" or cross out or blacken anything written (use single line then initial above)
"S" = Subjective	* Pt. relates hx * Pt tells of lifestyle or home situation * Pt. tells what he/she can no longer do * Voices complaint * States goals * Expresses emotions or response to treatment (Mood, focus, cooperation, energy level, pain level, quotes from Pt & family; "How it feels")
"S" = Subjective continued...	* Anything the pt expresses (concerns) that is/are relevant to the patient's case or present condition. * Use pt. * Organize subcategories * Quote patient to illustrate point * Can use family member information
"O" = Objective What went on during treatment. Chronologically if necessary.	* Measurable and observable * Therapist results of measurements * Provides info on what was done with pt on specific date * Important for Reimbursement & legal reasons (must show need for skilled occupational therapy)
"O" = Objective continued...	* Appropriate terminology * Correct spelling * Organize information so easy to read and understand; flows * Headings based on tests & measurements * Headings based on areas of body
"O" = Objective COMMON MISTAKES	* Fail to state affected body part * Fail to use measurable terms * Fail to state what is being measured (ex. flexion of Right UE) * BE VERY SPECIFIC
"A" = Assessment	* Includes everything from "S" and "O" that is not WNL (List of problems) * STG = short term goals * LTG = long term goals * Drawing conclusions & justifying decisions * Identify inconsistencies * Discussion of pt progress in therapy * Suggest further testing, treatment, etc.
"A" = Assessment continued...	Questions to ask examples: 1. Is pt better/worse today? 2. Did ROM increase/decrease? 3. Is pt showing progress/plateauing? 4. Do you need to rewrite goals?
"P" = Plan	Plan For Therapy: * Tells time and frequency of therapy ( 60 min per day/ 5 x per week/ 3 weeks) * Tells treatment pt will receive
Functional Maintenance Program	Program developed for clients discharged from therapy but remain in skilled nursing facility. Program facilitates skills present but not utilized unless compensations or adaptations are provided.
Informed Consent	Legal and ethical communication process between client and clinician that results in the client's authorization or permission to participate in evaluation and intervention.
Medical Necessity	Intervention is consistent with the diagnosis, and failure to provide intervention would jeopardize or significantly compromise the client's condition or quality of medical care.
Negative Prognostic Indicators	Signs that indicate barriers inhibiting rehab potential.
Positive Prognostic Indicators	Indicators that the client has good rehab potential, which is essential for third-party reimbursement.
Restorative Programs	Programs that facilitate the learning of new skills in an attempt to "restore" the client's previous abilities.
Screening	Process of determining if a client requires the skilled services of an OT practitioner. Helps to identify changes in functional status such as improvements or declines in physical or cognitive abilities.
Standardized Assessments	Methods used for data collection that have established reliability and validity.

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	Created by Robin Decker over 5 years ago