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Lecture 105 Documentation and Goal Writing
Terms in this set (58)
Review of Practice Framework
Performance in Areas of Occupation
OT Specific Documentation 1
Engagement in ________ Occupation
OT Specific Documentation 2
____ needs to relate to Areas of Occupation, ex. Dressing.
or Long Term Goals
OT Specific Documentation 3
____ needs to relate to specific Performance Skills needed to complete the Areas of Occupation, ex. Reaching to complete dressing.
or Short Term Goals
OT Specific Documentation 4
Needs to address?
"Increasing Engagement in Occupation to Support Participation in Context"
The POMR is ?
Problem Oriented Medical Record
Arranging the ______ ______ in a convenient way
Contains a listing of the?
Contains an _________Team Plan
Progress Notes written in chronological order, regardless of?
Client-Centered with use of?
SOAP Notes 1
S: Stand for?
SOAP Notes 2
S = Subjective which means 1
client's ________ of treatment provided; normally brief
SOAP Notes 3
S = Subjective contains 2
usually contains _________ by the patient/family in quotes
SOAP Notes 4
S = Subjective 3
May be longer after the_____ _____ with information provided about the initial interview
Ex. The patient complained of discomfort during the cooking task and asked for several breaks.
SOAP Notes 5
O: means 2
SOAP Notes 6
the OT practitioner's observations of the treatment provided, as it relates to the goals; contains?
measurable, quantifiable, & observable data that were collected,
Example, The patient required moderate assistance to open the jar during the cooking task. Or, the patient demonstrated an increase in sitting balance and required minimal assistance to sit upright on the tubbench.
SOAP Note 7
A: Means ?
SOAP Notes 8
This involves the OT practitioner's "________" of the meaning of events reported in the "O" section
SOAP Note 9
includes an ______ _______ about the pt's progress
Example, The patient has demonstrated continued limitations in opening containers necessary for meal preparation and is unable to complete those tasks with less than moderate assistance. Or, the patient has progressed to minimal assistance to complete bathing from a tubbench due to increases in sitting balance.
Soap Notes 10
SOAP Notes 11
This section includes information about what the OT practitioner plans to do next and may include: 6 things which are?
Continue with Plan of Care as established
Provide Family Education
Initiate Home Exercise Program
Upgrade/downgrade goals as appropriate
Refer to additional services
Discharge plan of care
Uses of the Medical Record 1
Client Care Management?
Way to record progress & information about the day to day aspects of the client's care
Uses of the Medical Record 2
Accounts for what services were provided and billed for; with monitor of frequency and duration of tx
Uses of the Medical Record 3
Document as if you will need the information to testify in court in the future; you may need it!
Uses of the Medical Record 4
Quality Improvement (QI)?
Process to oversee adequacy and appropriateness of care provided
Uses of the Medical Record 5
Provide data for medical research
Uses of the Medical Record 6
CMS, CARF, JCAHO; all review the medical record for notes to ascertain whether the extent and quality of services provided meet the standards of care that are set. Need to be in "compliance".
Uses of the Medical Record 7
Used as a teaching tool to gain information about clients and quality and appropriate OT intervention.
Uses of the Medical Record 8
Documents the incidence of certain diseases such as TB and HIV
Uses of the Medical Record 9
Client owns the information in the chart; can choose to read what was written.
Helpful Hints in Note Writing 1
Be as concise as possible without leaving out?
Helpful Hints in Note Writing 2
Helpful Hints in Note Writing 3
Report behavior and avoid _______ except in assessing your data.
The "A" section of a SOAP note indicates judgment.
Helpful Hints in Note Writing 4
Be sparse with _____ ______ that may be unfamiliar to the reader
Mechanics of Documentation 1
Always write in _____ _____ _____; blue may be acceptable in some settings.
waterproof black ink
Mechanics of Documentation 2
Never use ____ _____. It is considered illegal for altering a legal document.
Be prudent in using?
Only those approved by your facility.
JCAHO has several prohibited abbreviations 3
Correct errors with one line drawn through, write your correction and initial the change.
Mechanics of Documentation 4
If you inadvertently write in the wrong person's chart, draw a ____ ____through the entire entry and write "wrong chart" beside it with your signature.
Mechanics of Documentation 5
Be sure that all required _____ is present.
The signature includes first initial, middle initial, last name, and credentials.
Mechanics of Documentation 6
Be concise. Time is precious for those reading the chart.
Mechanics of Documentation 7
Use respect, use terms acceptable to your ______, ex. Patient, client, consumer, etc.
Mechanics of Documentation 8
Be prudent in using ________.
Only those approved by your facility.
JCAHO has several prohibited abbreviations
Writing Functional Problem Statements 1
Stick to Areas of Occupation from?
OT Practice Framework (OTPF)
Writing Functional Problem Statements 2
What is the underlying factor that is causing the problem?
Generally includes the _____ ______that are impaired.
Writing Functional Problem Statements 3
Could also include: _____ ______(routines, habits, roles), Context, Activity Demands, or Client Factors.
Writing Functional Problem Statements 4
State what the person "_____" vs. what the person "is":
Use "The consumer needs max assist..." vs.
"The consumer is max assist..."
Changing the PS into a Goal 1
Long Term Goals (LTG) are usually discharge goals or outcomes.
Usually accomplished by?
Changing the PS into a Goal 2
Short Term Goals (STG)/Objectives are usually daily goals that are met to progress towards the LTG.
Usually accomplished in?
The patient is unable to dress himself without maximal assistance and verbal cues.
The patient will dress himself independently using adaptive equipment by discharge.
The patient will maintain sitting balance needed to reach the clothing necessary for dressing himself by ...
Using FEAST 1
goal must pertain to function; stick with Occupation!
Using FEAST 2
- ex. The patient will...
Using FEAST 3
A: Action -?
An action verb is inserted here; ex. The patient will complete a simple cooking task...
Using FEAST 4
S: Specific Condition ?
- Level of assistance expected; ex. "At the wheelchair level", or "after skilled instruction"
Using FEAST 5
T: Timeline ?
- use of a date is
Usually the OT may be the one who writes the Goals, but it is a "________" process according to the AOTA Practice Guidelines.
The OT _____all documentation in the medical record made by the OTA.
Treatment is decided upon collaboratively by the OT and OTA to address the problem and should not be specifically addressed in the?
goals; Example: "Using wrist weights during the ADL, the patient will increase endurance needed to dressing independently by ..."
Don't corner yourself in!
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