Good Documentation; Ethical & Legal Considerations Flashcards
1
Q
What is the CARE module of documentation?
A
(C)larity: don’t beat around the bush
- short sentences or bullets
- “Client refused all attempts at therapy today and returned to her room.”
(A)ccuracy
- factual, chronological (document Monday’s treatment before doing Wednesday’s), consistent with protocol, timely
(R)elevant
- why was OT needed? what did OT do? what functional outcome was achieved or worked toward?
(E)xceptions
- unusual occurrences and event and what you did about it
- noncompliance or refusal
- why you are deviating from POC
