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OT 425 Intro to clinical documentation in occupational therapy

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University of Tennessee Health Science Center
Dept. of Occupational Therapy

Published in: Healthcare
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OT 425 Intro to clinical documentation in occupational therapy

  1. 1. Introduction to Clinical Documentation Stephanie Lancaster, MS, OTR/L, ATP Spring 2016 OT 425
  2. 2. Learning Objectives • Define the term clinical documentation as it is used in the field of occupational therapy. • Identify instrumental persons involved in the process of clinical documentation. • Explain why clinical documentation is important in the practice in OT. • Name at least 3 examples of specific types of documentation used by OT practitioners. • Write a SOAP note based on an observation of a simulated clinical observation.
  3. 3. Clinical Documentation What? Who? Why?When? Where?
  4. 4. What? *A record of information collected about the client, including assessment and intervention techniques used and clinical observations made by the health care professional.
  5. 5. Common Types of Clinical Documentation What? As part of the evaluation phase • Evaluation or screening report • Re-evaluation report During the intervention phase • Intervention plan • Service contact log • Progress report • Transition plan In the closing stages of the OT process • Discharge plan • Referral report
  6. 6. Fundamental Elements of Clinical Documentation What? • Client’s full name • Date and type of service provided • Professional terminology and abbreviations • OT practitioner’s name, signature, and professional designation Correct errands errors in this manner in documentation in paper format.
  7. 7. Who?
  8. 8. Why?
  9. 9. When?
  10. 10. Where?
  11. 11. Setting-specific Forms of Clinical Documentation: The SOAP Note S - Subjective O – Objective A – Assessment P – Plan Where?
  12. 12. The SOAP Note Problem: Dependence in wheelchair mobility S: Client stated that his hands often slip on the metal hand rims when he is propelling his wheelchair. O: Friction tape was placed on rims of w/c to improve client’s ability to grasp and propel w/c. Wheelchair mobility training outside over the grass and asphalt during functional activity provided. Client participated for 30 minutes with a 3-minute rest period required at the mid-point of the session. He experienced no difficulty propelling w/c during the session, including over uneven surfaces. A: Friction tape on w/c rims helped improve client’s ability to propel w/c. Client’s endurance for w/c mobility during functional activities has improved over the past week. P: Continue OT intervention targeting training in w/c mobility. Increase time and distance requirements for w/c mobility and add instruction in maneuvering w/c in and out of doors and up and down ramps as part of community mobility and functional activities addressed in OT.
  13. 13. Setting-specific Forms of Clinical Documentation: The SOAP Note S Where?
  14. 14. Setting-specific Forms of Clinical Documentation: The SOAP Note S - Subjective O – Objective A – Assessment P – Plan Where? O
  15. 15. Setting-specific Forms of Clinical Documentation: The SOAP Note S - Subjective O – Objective A – Assessment P – Plan Where? A
  16. 16. Setting-specific Forms of Clinical Documentation: The SOAP Note S - Subjective O – Objective A – Assessment P – Plan Where? P
  17. 17. Setting-specific Forms of Clinical Documentation: In Early Intervention/Schools IFSP – Individualized Family Service Plan Where? IEP – Individualized Education Plan
  18. 18. Setting-specific Forms of Clinical Documentation Where? The Narrative Note AROM EOB UB d/t s/p d/c Sample Narrative Note: Client activity participated in eating during dining retraining as well as R UE strengthening program. Client ate 75% of meal using adapted utensils and required minimal assistance for cutting meat. Established treatment plan should continue.
  19. 19. Setting-specific Forms of Clinical Documentation Where? The Progress Note Sample Weekly Progress Note: Client has been treated daily for eating/mealtime retraining and R UE functional strengthening program. Using adapted utensils, client has eaten 75% of meal with min. assistance for cutting meat. Previously, client ate 50% of meal and required mod. assistance for cutting meat. Goal: Client will eat independently with adapted utensils within one week.
  20. 20. Setting-specific Forms of Clinical Documentation Where? The OT Evaluation
  21. 21. References American Occupational Therapy Association. (2009). Guidelines for Supervision, roles, and responsibilities during the delivery of occupational therapy services. American Journal of Occupational Therapy, 63, pp. 797—803. American Occupational Therapy Association. (2010). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 62(Suppl), S106—S111. Boyt Schell, B. A., Gillen, G., & Scaffa, M. E. (2013). Willard & Spackman’s occupational therapy (12th ed). Baltimore, MD: Lippincott Williams & Wilkins. Clifford O’Brien, J. & Hussey, S. M. (2012). Introduction to Occupational Therapy (4th ed). St. Louis, MO: Elsevier Mosby, Inc. Hinojosa, J., Kramer, P., & Crist, P. (2010). Evaluation: Obtaining and interpreting data (3rd ed.). Bethesda, MD: AOTA Press.

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