Phys Dis Chapter

Front 1

documentation begins when

Back 1

immediate on receipt fo the intial referral

Front 2

what should written record include

Back 2

clarification of referral intial evalustaion, results , and ongoing daily and or weekly progress nots

Front 3

purpose of documentation is to

Back 3

atriclate the rational for povison of ot services
reflect the ot practioners clinical reasoning
communicate info about the clien from the ot perspective
creat a chronologi record of client status ot servicesprovide to the client outcomes

Front 4

ots responsibility fo rdocumuntation

Back 4

papring ceratin reporst as delegated by the ot assisin in the preparation of the intervention plan document progress report any necessary revisision in th interventionplan based on reeval and complete discharge summary in collabartion with ot

Front 5

vearcit

Back 5

concept of ethics that is based on virtues of truthfulness cando and honesy ot practioner should record and report in an accurate and timely manner and ensure that documetaion for reimbursement purposes is completed in accordance with applicable laws guidlene and regulations

Front 6

documentation must...

Back 6

well organized, contain onl pertinent nfo., and be objective and accurate

Front 7

quality management process

Back 7

in this process chars are aduite by internal staff can be a learning opportunity

Front 8

what are official records of this content

Back 8

requitements based on internal systems, licensing agencies, accreding bodies, and third party payers

Front 9

subjective soap note

Back 9

what ahs been said subjectively by the client or what has been reported by significant others

Front 10

objective soap note

Back 10

observable and measurable data derived rom evaluation and treatment resuults

Front 11

asessment

Back 11

the opinion interpretation or asessmen of the results of th clients functinla performance and anticipated outcomes inclundin a problem list and long and shorterm goals

Front 12

plan

Back 12

the treatment plan including eh frequence and duration of treatmnet

Front 13

narrative notes

Back 13

less structured than doap format used to document client contact thatnot necessaridly during treatment

Front 14

flow sheets

Back 14

tyrpically form of a grid efficeitn way to quickly document numbers of reps of an exerscise or level of independence for a functional activity only room for objective data

Front 15

functional outcomes four main components

Back 15

first the outcome must address performance
musth have measurable criteria to indicate when the outcome has been met
the outcome will need to specify specific conditions under widcht ehprformanc should be completed for a list of levels of assistance that can be usd to defineconditions
the outcome will need to give a time frame for completion

Front 16

functional outcomes can be achieved by

Back 16

a series of short term intervention goasl or objectives that are designed to move the client throught the intervention process week by week

Front 17

when a physcisian referral is required it should include

Back 17

ot treatmen diagnosis onset dat a request for evaluation and other specific treatment orders the date the physicians signature
and frequency of duration of ot services

Front 18

when one or more required items for physicians order is midding from the referral it is important to do waht

Back 18

clarify the order fills out the form after initial eval is completesent to phscian along with the initial eva for phsicians signature

Front 19

the two steps the initial evaluaton process compriimises

Back 19

first step to identify the clents occupational profile where the clents needs probles and concers are identif with priorites set the second step is analysis of the clents occupational performance factors that interfere with performance of functional acctivit are identified and treatment gals are established

Front 20

occupational profile

Back 20

addrssses the clients interst valuses and needsinfo collected during intiala eval bus also during subsequent therapy vistisoutcomes continuously modified based ont this

Front 21

occupational pefromance analysis is

Back 21

a process for espablishing the cleints Vaseline starus accuracy is critical

Front 22

initial evaluaton freport

Back 22

ot primary responsibily can be divided into four sections
description of the clients occupational profile
analysis of the clents occupational performance
prioritizing areas of occupation and occupational performance
intervention plan