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OT Documentation and Professional Issues
Terms in this set (78)
OT Code of Ethics
beneficience, veracity, nonmaleficience, autonomy, justice, fidelity
OT Core values
altruism, dignity, equality, freedom, justice, prudence, truth
Standards for Continuing Competence
OT Types of documentation
screening, evaluation, intervention, outcomes
Education and Licensure requirements
Graduation from OT program accredited by ACOTE, Supervised fieldwork experience, NBCOT exam passed, Fulfills state requirements for licensure, certification or registration
NYS OTA requirements
Fee $147, complete a two-year associate degree program for occupational therapy assistants, be of good moral character,
be at least 18 years of age,
meet education and examination requirements. You must submit an Application for Licensure/Authorization (Form 1) and the other forms indicated, along with the appropriate fee, to the Office of the Professions at the address specified on each form. It is your responsibility to follow up with anyone you have asked to send us material.
What does SOAP stand for?
Subjective, objective, assessment, plan
What does COAST stand for?
client, occupation, assist level, specific condition, timeline
Management in OT
Manager, Leader, supervisor
What does a manager do?
-equipment and space management and supervision. a.k.a. "Rehab Director"
-policy and procedure development and adherence
-maintaining staff satisfaction and retention
What does a leader do?
one who possesses the skills to direct, guide, inspire, coach, mentor and motivate, maintain ethics within oneself and everyone else, embrace change and remain stable, commit to quality care, advocate for patients and employees, delegate to make things happen
reward based, clear expectations are determined, employees are expected to perform
inspirational, stimulates thinking and creativity, engages all for the good of the department
one who oversees the work of others, Supervision of a student is an honor - you have demonstrated the clinical, interpersonal and professional skills that will benefit a student.
When can you supervise a Level 1 student?
Can begin supervising when competency is established - may depend on length of time, complexity of caseload, skills required.
When can you supervise a Level II student?
After one year of practice as an OTA; this role requires documentation, teaching, supervision - student is under your license.
Health literacy consists of related skills and competencies that affect a person's ability to:
-navigate healthcare environments
-seek and acquire healthcare services
-follow instructions for health maintenance, disease prevention and treatment
-understand and apply basic health information within the context of personal knowledge of body systems and functions and within cultural beliefs about health and disease
Health literacy becomes important when:
-a person fills out a health history form
-reads instructions for taking a medication
-decides whether to call a health professional
-visits a family member in the hospital
Health Literacy challenges:
-disparity between higher and lower income populations in both access to and frequency of use of the internet and of high quality information sites
-the level of education and proficiency in finding and using credible sources of heath information on the internet varies widely across different populations by age, ethnicity, and income level.
why is health literacy important in OT?
Awareness of the client's level of health literacy and teaching them at their appropriate level is crucial to the OT practitioner's ability to teach clients new skills and knowledge to support function and participation in home and community environments.
Is not just about reading and understanding written health information. It is about understanding numeracy, general concepts, visuals and basic communication skills
Assessing health literacy of clients
Find out our learner's needs, abilities and readiness to learn health information.
the process of actively developing and practicing appropriate, relevant, and sensitive strategies and skills in interacting with culturally different persons. A set of behaviors, attitudes and policies that come together and enables professionals to work effectively in cross-cultural situations.
cultural competence entails
-understanding the importance of social and cultural influences on patient's health beliefs and behaviors
-considering how these factors interact on multiple levels of the healthcare delivery system
-devising interventions that take these issues into account to assure quality healthcare delivery to a diverse patient population
Clinically, cultural competence means:
having the self-awareness, knowledge, skills and framework to make sound ethic and culturally appropriate decisions
Competence in Cultural Competence means:
-learning new patterns of behaviors and effectively applying them in appropriate settings:
-involving the extended family in the intervention process
-addressing elderly persons more formally than younger clients
-acknowledging and working with traditional and/or faith healers
-being cautious about touching
-Engaging in small talk at the beginning of a session, which is considered good manners and keeps one from appearing rushed
-Conducting the session in the preferred language of the client or arranging for a professional interpreter
-Adding culturally related questions during the evaluation process
-Can result in compromised quality of care
-Non-compliance by the client
-inability to recognize differences
-fear of the new or unknown
-denial and inability to look at the individual needs of the client and his or her family
- Outcomes range from frustration, confusion or shame, to anger in the client, family and practitioner.
OTs are autonomous practitioners who are able to deliver OT services independently.
-are accountable for the safety and effectiveness of the OT service delivery process:
-must be directly involved in the delivery of services during the initial evaluation and regularly throughout the course of intervention and outcome evaluation
-OT is responsible for determining when to delegate responsibilities to an OTA
- demonstrate and document service competency for clinical reasoning and judgment during the service delivery process as well as for the performance of specific techniques, assessments and interventions used.
Supervision: frequency, methods and context of supervision are dependent on:
-complexity of clients needs
-number and diversity of clients
-skills of the OT and OTA
-type of practice setting
-requirements of the practice setting
-other regulatory requirements
Methods or types of supervision:
-direct face-to-face contact
Direct Face-to-Face Supervision includes:
Indirect Supervision includes:
Documentation of a Supervision plan may include:
-frequency of supervisory contact
-methods or types of supervision
-context areas addressed
-evidence to support areas and levels of competency
-names and credentials of the persons participating in the supervisory process
OTA Responsibilities during OT Service Delivery:
-Delivers OT services under the supervision of and in partnership with the OTR.
-Demonstrate service competency with their delegated responsibilities
-demonstrate and document service competency for clinical reasoning and judgment during the service delivery process as well as for the performance of specific techniques, assessments and interventions used.
When delegating OT services, the OTR considers:
-complexity of the client's condition and needs
-knowledge, skill and competence of the OT practitioner
-Nature and complexity of the intevention
-needs and requirements of the practice setting
Evaluation Process - OTR Responsibilities
-OT directs the evaluation process
-Is responsible for directing all aspects of the initial contact during the evaluation including:
- determining the need for service
- defining the problems within the domain of OT that need to be addressed
- determining the client's goals and priorities
-establishing intervention priorities
-determining specific further assessment needs
-determining specific assessment tasks that can be delegated to an OTA
-initiates and directs the evaluation
-interprets the data
-develops the intervention plan
-interprets information provided by the OTA and integrates that Information into the evaluation and decision making process.
Evaluation Process: OTA
Contributes to the evaluation plan by:
-implementing delegated assessments
-providing written and verbal reports of observations and client capacities to the OTR.
Intervention Planning: OTR
Has overall responsibility for the development of the OT intervention plan
-collaborates with the client to develop the plan
Intervention Planning: OTA
-collaborates with the client to develop the plan
-is responsible for being knowledgeable about evaluation results and for providing input into the intervention plan, based on client's needs and priorities.
Intervention Implementation: OTR
Has overall responsibility for implementing the intervention
-is responsible for providing the appropriate supervision to the OTA
Intervention Implementation: OTA
-is responsible for being knowledgeable about the client's OT goals
-selects, implements, and makes modifications to therapeutic activities and interventions that are consistent with demonstrated competency levels, client goals and requirements of the practice setting
Intervention Review: OTR
-Responsible for determining the need to continue, modify or discontinuing OT services
Intervention Review: OTA
-contributes to this process by exchanging information with and providing documentation to the OTR about the client's responses and communications during intervention.
Outcome Evaluation: OTR
-responsible for selecting, measuring and interpreting outcomes that are related to the client's ability to engage in occupations
Outcome Evaluation: OTA
-responsible for being knowledgeable about the client's targeted OT outcomes
-provides information and documentation related to outcome achievement
-may implement outcome measures
-provide needed client discharge resources
Supervision of OT Aides: OTR
OTR oversees the development, documentation and implementation of a plan to supervise and routinely assess the ability of the OT Aide to carry out non-client and client related tasks.
-Non-client tasks include clerical and maintenance and prep of the work area or equipment
-Client related tasks must be:
- outcome anticipated and predictable task
-environment is stable and will not require judgment, interpretations or adaptations by the aide
-client has demonstrated previous performance ability in executing the task
-task routine and process have been clearly established
Supervision of OT Aides: OTA
-May contribute to the development and documentation of the plan to assess the ability of the OT Aide.
-Can supervise the aide
When supervising the Aide, the supervisor must ensure that the Aide:
-is trained and able to demonstrate competency in carrying out the delegated task and using equipment, if appropriate, with the specific client
-knows the precautions, signs and symptoms for the particular client that would indicate the need to seek assistance for the OTR or OTA
Supervision of the OT Aide
Needs to be documented, including:
-information about frequency and methods of supervision used in the content of supervision
-names and credentials of all persons participating in the supervisory process.
Standards for Continuing Competence: Knowledge
Demonstrate understanding and integration of the information required for the multiple roles and responsibilities they assume. Must Demonstrate:
-Mastery of the core of the practice
-expertise in client-centered OT practice and related primary responsibilities
-Integration of relevant evidence, literature and epidemiological data related to OT Practice
-Integration of current AOTA documents and legislative, legal and regulatory requirements into OT/evidenced based practice
-The ability to seek new knowledge to meet client's needs and those of the profession
Standards for Continuing Competence: Critical Reasoning
Use reasoning processes to make sound judgments and decisions. Must Demonstrate:
-deductive and inductive reasoning in making decisions specific to roles and responsibilities
-Problem solving skills
-ability to analyze occupational performance influenced by client and environmental factors
-Reflect on one's own practice of OT
-Management and synthesis of information from different sources to support decision making
-Application of evidence, research findings, and outcome date to make decisions
-revise decision making processes by assessing previous assumptions against new evidence.
Standards for Continuing Competence: Interpersonal Skills
Develop and maintain professional relationships with others within the context of their roles and responsibilities. Must demonstrate:
-Use of effective communication methods that match the therapeutic needs of the clients
-Cultural competence through interaction with people from diverse backgrounds
-Modify one's professional behavior through feedback from colleagues, supervisors and clients.
-Collaborate with clients and caregivers to obtain optimal consumer outcomes
-Ability to develop, sustain and refine interpersonal and team relationships to meet identified outcomes
Standards for Continuing Competence: Performance Skills
Demonstrate their expertise, proficiencies and abilities to competently fulfill their roles and responsibilities in OT by the delivery of services. Must demonstrate:
-practice grounded in the core of OT
-Therapeutic use of self, client-centered occupations and activites, the consultation process and education process to bring about change.
-Integrating current evidence-based practice techniques and techologoies
-Updating performance based on evidence-based literature with consideration given to client interest and practitioner judgment.
-Using quality improvement processes that prevent practice error and optimize client outcomes
Standards for Continuing Competence: Ethical Practice
Indetify, analyze and clarify ethical issues or dilemmas to make resoposible decisions within the changing context of their roles and responsibilities. Must demonstrate:
-Understanding and adherence to the OT code of ethics, applicable laws and regulations
-Use of ethical principles and the profession's core values to understand complex situations
-The integrity to make and defend decisions based on ethical reasoning
-Integration of varying perspectives in the ethics of clinical practice.
Demonstrating concern for the welfare of others.
Treating clients with respect in all interactions
Treating all people impartially and free of bias.
and personal choice are paramount in a profession in which the values and desires
of the client guide our interventions.
Expresses a state in which diverse communities are inclusive; diverse communities are organized and structured such that all members can function, flourish, and live a satisfactory life
Using clinical and ethical reasoning skills, sound judgment, and reflection to make decisions in professional and volunteer roles.
Provide accurate information in oral, written,
and electronic forms.
Demonstrate a concern for the well-being
and safety of the recipients of their services.
Refrain from causing harm
Respect the right of the individual to self-determination, privacy, confidentiality, and consent.
Promote fairness and objectivity in the
provision of occupational therapy services.
Provide comprehensive, accurate, and
objective information when representing the profession.
Treat clients, colleagues, and other
professionals with respect, fairness, discretion, and integrity.
Standards for Continuing Competence list:
Levels of Assistance (7)
No assistance or supervision needed
Necessary items provided prior to task
Supervision (assist level)
Supervision without physical contact
1-24% of effort from one helper
25-49% effort from one helper
50-74% effort from one helper
75-100% effort from one or more helpers
Pt unable to perform at this time
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