2. The OT Process Continuum (Part One)
What is the occupational therapy process?

3. The OT Process Continuum
Evaluation
Intervention
Outcome
Name each stage of the OT process.
Identify the purpose of each stage and any steps or components of the stages.

4. What is the purpose of the occupational profile?
Identify 5+ things included in an occupational profile.

5. Intervention implementation
OT Intervention Plan
What intervention can best help my client?
What is an OT intervention plan?
Intervention plan
Intervention implementation

6. Steps in OT Intervention Planning
Problem identification
Solution development
Plan of action
Problem identification
Solution development
Plan of action:
3a. Creation of long- and short-term goals
3b. Determine intervention methods
Analyze & interpret data from evaluation
Development of a written plan which includes:
strengths and weakness of client
interests of client & caregiver(s)
estimate of rehab potential
expected outcomes
recommended frequency & duration of intervention
recommended methods and materials
apparent environmental & time constraints
plan for re-evaluation
plan for discharge

7. OT Intervention Approaches
Create/promote (health promotion)
Establish/restore (remediation, restoration)
Maintain
Modify (compensation, adaptation)
Prevent
See p. S33 in OTPF (3rd ed.)

8. Introduction to Documentation (Part Two)
Clinical Documentation
What?
Who?
Why?
When?
Where?
Overview of the topic:
A service management function required of OT practitioners to provide an accurate record of service
Provides a justification for OT intervention
When does documentation take place, both in the OT process and scheme of the evaluation and intervention?
What does documentation look like (pay attention to key terms)?

9. Documentation Reflected through documentation:
Statements made by client/caregiver
Observations of OT practitioner
Professional judgment of OT practitioner
Recommendations and plan of action
Clinical documentation – a record of the status of the client, techniques used, and progress the client makes in therapy.
Essential to intervention planning and communication between team members and others
Becomes part of the client’s permanent record – at the facility and often for third-party payers
Must be organized, legible, concise, accurate, complete, grammatically correct, and objective
Documentation should reflect the nature of services provided and the clinical reasoning of the occupational therapy practitioner
It should provide enough information to ensure that services are delivered in a safe and effective manner.
Documentation should describe the depth and breadth of services provided to meet the complexity of individual client needs. The client’s diagnosis or prognosis should not be used as the sole rationale for occupational therapy services.

10. Common Types of Clinical Documentation
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
Common Types of Clinical Documentation
Common types of documentation used during the OT process -
Evaluation or screening report – contains info on referral source and data gathered during the eval process. Provides client’s occupational profile, analysis of occupational performance, factors that support or inhibit performance, and expected outcomes of intervention (Re-evaluation report – provides recs for changes to services, goals, freq, or other necessary services)
Intervention Plan - client’s goals and approaches used to reach those goals, identifies frequency and duration of service, service provider, and location of service
Service contact log or daily note – specific interactions between client and OT as an ongoing log that includes date, length of tx, interventions, and client’s response. Telephone/ communications and meetings with other services providers are included.
Progress report, - summarizes intervention and client’s progress towards goals. Summarizes new data and modification to the intervention plan and gives recommendations for continuation or discontinuation of service. Format and procedures vary between settings and reimbursement mechanisms.
Transition plan – describes client’s progression from one type of setting to another (ex. rehab to SNF). Provides info on client’s current status, reason and time frame for transition, and recommendations for services/equipment/environmental modifications/training needs going forward
Outcomes - Discharge plan – completed at end of intervention. Summarizes changes in client’s ability to participate in occupations since start of services and recommendations for follow-up or further services as needed, Referral report – may also involve ordering equipment

11. Fundamental Elements of Clinical Documentation
Client’s full name
Date and type of service provided
Professional terminology and abbreviations
OT practitioner’s name, signature, and professional designation
Elements present in all forms of clinical documentation –
Client’s full name + identification number
Date and type of service provided
OT practitioner’s name, signature, and professional designation – including counter-signature for OTA or student
Professional terminology and abbreviations – as accepted in specialty area of practice or in the specific setting
Errors are to be corrected by a single line drawn through and then initials – no white-out or erasures in paper documentation
Storage and disposal of records as indicated by law and facility policy (HIPPA compliance for confidentiality)
Correct errands errors in this manner in documentation in paper format.

12. OT’s and OTA’s are responsible for clinical documentation as a method of communication with the client, caregivers, third-party payers, other allied health professionals and medical professionals, educators, attorneys and other parties in the legal system (judges, juries), accreditation board reps, and administrators.

13. Why?
Provides a justification for services while showing the OT’s clinical reasoning and professional judgment
Records the client’s journey
Communicates information about the client from the occupational therapy perspective
Reflects the OT’s professional continuum of services in the OT process from start to finish
Shows the outcome of the intervention
Used for billing and professional communication
Serves as an accurate record of service - “If you didn’t document it, it didn’t happen!”
Crucial for legal and ethical purposes
Malpractice, fraud, negligence, and/or incompetence
Medicare and governmental payer sources
Legal documents that are part of the client’s health records

14. When?
Documentation of occupational therapy services is necessary whenever professional services are provided to a client.
OT’s and OTA’s determine the appropriate type of documentation structure and then record the services provided within their scope of practice.
Formats and procedures for when to document are site-specific – as are the “where” and “how” parts of the documentation process
AOTA’s Standards of Practice for Occupational Therapy (2010) states that an occupational therapy practitioner documents the OT services and “abides by the time frames, format, and standards established by the practice settings, government agencies, external accreditation programs, payers, and AOTA documents” (p. S108). These requirements apply to both electronic and written forms of documentation.
Both for accuracy and as part of providing the most effective intervention possible, it is best to document as soon as services are provided as possible – although deadlines for creating/updating the record vary

15. Where?
Setting-specific requirements – Documentation is directly influenced and outlined by the setting type
Paper vs. Computer based documentation
Dictation
Checklist vs. Narrative format vs. Mixture of both
Reports may be named differently or combined and reorganized to meet the specific needs of the setting. Occupational therapy documentation should always record the practitioner’s activity in the areas of screening, evaluation, intervention, and outcomes (AOTA, 2008) in accordance with payer, facility, and state and federal guidelines.

16. https://play.kahoot.it/#/k/c6d792a5-4d10-40f2-834b-6e2cb4f70e4b

17. The SOAP Note Problem: Dependence in wheelchair mobility
Client stated that his hands often slip on the metal hand rims when he is propelling his wheelchair.
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.
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.
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.
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.

18. Setting-specific Forms of Clinical Documentation: In Early Intervention/Schools
IEP –
Individualized Education Plan
IFSP – Individualized Family Service Plan
IFSP - Birth through the day before the child turns 3 years old
Required through the IDEA Part C
State agency coordinates service delivery – in TN it is Tennessee Early Intervention Services (TEIS).
Includes: summary of child’s occupational performance, family concerns/priorities/resources, summary of expected outcomes, frequency/duration, child’s natural environment, important dates, service coordinator, and transition plan for toddler to enter preschool.
IEP - Children ages 3 to 21 years
Required through IDEA Part B
Special education services and related services
Includes: child’s educational performance, annual goals, special education and related services, participation with non-disabled peers, participation in statewide/district-wide tests, important dates, transitions to adult/work settings, and measurement of progress.

19. Setting-specific Forms of Clinical Documentation
The Narrative Note UB
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.
s/p
d/t
Open writing style in a paragraph format
Little to no headers or titles
Often includes professional jargon such as AROM, ADLs, EOB (edge of bed), min assist, UB, mod I, d/t (due to) or 2* (secondary to), d/c
Abbreviations can be tricky – beware of the context in which they are being used. Story about first anatomy quiz – MCP, PIP, DIP, HIP
Example narrative note - O & H p. 128
AROM
d/c
EOB

20. 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.
Written on a more intermittent frequency level depending on the site – often weekly or bi-monthly (quarterly in schools)
Often include professional jargon
Focus on problems and outcome goals specified in evaluation report and intervention plan (or IEP in school system)
Example weekly progress note - O & H p. 129

21. Setting-specific Forms of Clinical Documentation
The OT Evaluation
Tells a story based on the client’s occupational profile – includes:
Heading: Occupational Therapy Initial Evaluation Report
Subheading: Divided into two columns
Client’s Name:
Date of Birth:
Date of Evaluation:
Chronological Age:
Section One: Background information/Client profile
Section Two: Input from client and/or caregiver(s)
Section Three: Results of formal and/or informal testing
Section Four: Clinical observations
Performance Areas
Performance Components
Section Five: Summary
Section Six: Recommendations
Section Seven: Closing – therapist’s name, signature, and credentials
Example initial assessment report - O & H pp

22. https://play.kahoot.it/#/k/e337aa22-7787-40d8-8397-51ddef8e57d1

23. Always remember … Let your objective documentation paint the picture.
What if a client doesn’t participate in a session?
Always document as if this were to be the most litigated and public patient relationship you have ever seen.  
NEVER use the words 'poor'.  Always use objective information, as you never know at what point who will be reading it. 
Let your objective documentation paint the picture.  
Poor compliance is too subjective.  
Poor participation is too subjective.  
Poor motivation is too subjective.  
Instead, write something like:  
Pt. presented with 3 activities for participation in UE exercises.  
Pt. completed 0/3 in xxxxx activities.  
Pt. completed 1/3 in xxxxx activities 
Pt. completed 1/3 in xxxxx activities with max. vb. cue to initiate (or whatever part of participation is getting hung up)  
Pt. declined xxxx activities stating, "......".  
Pt. participated in _____ % of activities with max. vb. cue and ____ with mod. vb. cue. to initiate.   
Educated pt. on importance of therapeutic exercise as an intervention to reach goal of donning shirt. Pt. responded, stating:  
Assessment:  
Motivation and participation factors continue to impact pt. ability to progress with goals.  Pt. cont. to be max assist with donning shirt.  
Reviewed OT goals with pt. and she agrees/does not agree that these goals remain focus of OT Intervention.  
Plan:  Continue with OT goals.  Notify pt., nsg. and family If motivation and participation continue to be a factor limiting progress, meet with pt. and care team to discuss discontinuation from OT  
Think in terms of this:
If I'm a law judge, I'm going to look at your documentation and the first questions I'm going to ask:  
1. Why were you seeing this patient?  Did she agree to work on this? Was this her goal?   (eval - check)
2. Was the patient participating?  How do we know?  How do we know that you tried?  What did you try?  Could you have tried a different way? Did you?  (documentation - check) 
3. You say poor motivation and participation.  What does that mean exactly?  How do you know that's what you mean?  Can you reference it in your document? Because if it's not there, it didn't happen.  (initiation is a component of motivation and participation - check).  
4. So okay, you say this patient wasn't really motivated because she didn't participate in the exercises you gave her.  You tried a different activity approach.  That is good.  Did you talk to her about her participation and her goals?  What did she say?  What was your professional assessment then?  
5. Okay, I've seen that she wanted therapy.  I've seen that you tried to provide therapy in various ways.  I've seen that you tried to talk to the patient about lack of progress and participation. 
Let your objective documentation paint the picture.

24. One Last Note About Documentation (for now …)

25. 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.