Chapter 17 : Medical Records and Documentation Flashcards Preview

OTA 110: Occupation Skills - Psychosocial > Chapter 17 : Medical Records and Documentation > Flashcards

Flashcards in Chapter 17 : Medical Records and Documentation Deck (13):

What is the most important task of the OT practitioner?



What are the 2 approaches to organizing notes?

1) source-oriented record
2) Integrated record


Notes are organized into smaller sections, each for a different discipline, so for example, all the OT notes are in one place

Source-oriented record


All of the notes from different disciplines are in one section; the notes are written one after the other

Integrated record


When was the problem oriented medical record (POMR) introduced?

1969 by Lawrence Weed


The problem oriented medical record (POMR) is organized into 3 major sections.......

1) the database
2) the problem list
3) the reports of plans and progress


Identifies the assessments that were used, the results of these assessments, the therapists interpretation of the results, and the therapist's treatment plan - the emphasis is on obstacles to the clients's engagement in occupation

evaluation reports


Spells out the goals established, the methods to be used, the frequency of treatment, and the time by which the therapist expects the goals to be reached

intervention plan


Documents individual OT sessions or contacts an the service provided

contact, treatment, or visit note


Documents treatment periodically, updating information on progress toward functional goals, changes to the plan, and coordination of care

progress report


Documents the results of the reevaluation, compares these to the initial evaluation, and recommends changes or continuations in the plan

reevaluation report


Written in preparation for a move from one setting to another - summarizes all pertinent info and recommendations

transition plan


Gives a concise description of the entire course of OT intervention since first contact and includes assessment of outcomes

discharge or discontinuation report