Week 14 and 15 Flashcards
The Purpose of Client Care Documentation
-Client care management, referral for other services, reimbursement, utilization review, legal document, quality management, accreditation, education, business, development, client access
Documentation in OT
-Initial evaluation (Occupational Profile, Assessment Results), Intervention planning, Intervention, Intervention review, Outcomes
-Documentation uses professional language (OTPF) (Domain & Process)
Health Records
-Any documentation is part of the health record
-Mainly electronic
-EHRs are organized by. source-oriented information, integrated information, problem-oriented
Formats of Documentation
-Handwritten, electronic, mixture
-Formats: SOAP, DART, PIE, SOAPIE, SBAR, SOAPIER, FOCUS
Documentation Notes
-Client name/ Case #, type of document, date of service, problem/goal, what the client did, skilled service provided, referrals, signature
Documentation Rules
-Must have a date, no spaces, grammar, professional terminology, legibility, proofread, etc.
“S” in SOAP Notes
Subjective
-What the client says
“O” in SOAP Notes
Objective
-What you saw the client for
-Observe the client doing or the barriers that prevented the, from doing
-Measurement from assessments results
-De-emphasize/reclassify the treatment activity
“A” in SOAP Notes
Assessment
-Professional opinion about the O section
-impact of client factors on other occupational areas or function
-Why is skilled service needed
“P” in SOAP Notes
Plan
-Therapist’s plan for treatment
-What will happen next
-Communication and collaboration the need to refer client for other services
Structures and systems that create and impact federal and state legislation and regualtions
AOTPAC
Further the legislative aims of the Association by influencing or attempting to influence the selection, nomination, election, or appointment of any individual to any Federal public office, and of any occupational therapist, occupational therapy assistant, or occupational therapy
student member of AOTA seeking election to public office at any level.
Minnesota Board of Occupational Therapy
To protect the public through effective licensure and enforcement of the statutes and rules governing occupational therapy practice to ensure a reasonable standard of competent and ethical practice.
-Verifies that practitioners are qualified to practice OT in MN
Payment for Services
-Public/Government, Idea (Part B and C), Workman’s compensation,
Payment Rules: Medical Settings
Billing is usually in 15-minute increments called
units table 3-6 page 27
– Billing codes
– ICD-10 – condition codes
– CPT codes: treatment codes
– Payment is based on outcomes Patient Driven
Payment Model (PDPM)
– MDS- Minimum Data Set
– Form used to assess where a client is at and
what services/supports are required for care
– Section F for activities staff
– Section G for Rehab
– Billed based on skilled services/Outcomes
– Tracks patient outcome
Influence of Payer Systems on Documentation
HIPPA
Health Information and Portability Act
FERPA
Family Educational Rights and Privacy Act
Ethical Considerations
– Documentation is a legal record
– Denials/Appeals
– Illegible, Incomplete, Abbreviations unknown, Complete list on page 26
– AOTA is resource for up-to-date information
– CMS.gov
- Regulations, Supervision, Billing
– Billing fraud
– High productivity issues (now less, but other ways will surface, Facilities pushing to increase caseload or keep patients longer than they should or doing group therapy
– Students who document must have co-signer of
supervisor
-COTAs may have to have documentation co-signed
(depending on type of workplace and regulations in
place)
– Rehab Aides are not allowed to document
NBCOT Exam
COTA Domain
- COLLABORATING AND GATHERING INFORMATION
* Assist the OTR to acquire information regarding factors that influence
occupational performance on an ongoing basis throughout the occupational
therapy process. 28% - SELECTING AND IMPLEMENTING INTERVENTIONS
* Implement interventions under the supervision of the OTR in accordance with
the intervention plan and level of service competence to support client
participation in areas of occupation throughout the occupational therapy
process. 55% - UPHOLDING PROFESSIONAL STANDARDS AND RESPONSIBILITIES
* Uphold professional standards and responsibilities by achieving service
competence and applying evidence-based interventions to promote quality in
practice. 17%
Minnesota Licensure
Credentials to work with reimbursors
- Medicare 65+ y/o federal program
-Want registered/credentialed therapists - Medicaid Medical Assistance
- Private Insurance
-Often specify the registered therapist
Standards of Practice
Official document of the profession used to define the minimum standards for the practice and delivery of OT
1. Defines the education, examination and licensure requirements
2. Definition of terms
3. Professional Standing and Responsibility
4. Service Delivery
5. OT Process
6. Helps practitioners and organizations determine what should and what can be
done
7. Ethical guide
