Study sets, textbooks, questions
Upgrade to remove ads
Documentation in RT
Terms in this set (24)
what is documentation linked to?
the entire APIE process
why is documentation important?
- critical communication piece between treatment team
- provides rationale for selected treatments/activities
- justification of your program can depend on documentation
- to see if the client is progressing
- for legal and liability reasons
what should you focus on?
observed facts-what did you see, hear, feel
what is the KISS method
keep it short and simple
what else should you note?
- improvements and declines
- assistance level needed to complete activity (need help from therapist?)
should you scratch out, erase, or white-out notes?
no (just put a line through it)
what should you withhold?
non-clinical, unsubstantiated judgements
what should you avoid?
- jargon (too much medical abbreviation)
- long narratives and wordiness
what is the recommended structure of narrative notes?
- activity's purpose
- pt/client's involvement
- therapist's involvement
- outcomes/progress towards goal(s)
what are SOAP notes?
subjective, objective, assessment, plan
what is the subjective portion of SOAP?
data gathered from client or family, important statements
what is the objective portion of SOAP?
data collected through observation, measurement, other sources of documentation (i.e. client chart)
what is the assessment portion of SOAP?
your clinical judgement of the meaning of subjective/objective data
what is the plan portion of SOAP?
general plan or approach that will address needs (can state initial plans, revision of plans, or new plans - what's next forward thinking)
what are BIRP notes?
behavior, intervention, response, plan
what is the behavior portion of BIRP?
patient behavior that pertains to the intended treatment outcome and includes subjective and objective info
what is the intervention portion of BIRP?
description of interventions to address the treatment outcomes
what is the response portion of BIRP?
patient response to intervention
what is the plan portion of BIRP?
therapist plan for care, treatment, program going forward
what are DARP notes?
data, assessment, response, plan
what is the data portion of DARP?
patient behavior that pertains to the intended treatment outcomes and includes subjective and objective info (like B in BIRP)
what is the assessment portion of DARP?
your clinical impression given the subjective and objective data from above
what is the response portion of DARP?
the client's response to intervention/plan
what is the plan portion of DARP?
therapists plan moving forward with care, treatment, and program
Sets found in the same folder
Reliability and validity in Assessments
Functional and Participation Assessments
Other sets by this creator
Content Quiz 5
ATRA Standards of Practice
Activity and Task Analysis
Treatment Planning: Writing Goals and Objectives