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Creado por Robin Decker
hace casi 6 años
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Pregunta | Respuesta |
Documenation | * Done daily (often) * All healthcare professionals * SOAP format most common * Integral part of patient care process * Significant time spent documenting daily |
Reasons to Document | * Legal * Communication * Reimbursement * Decisions regarding Discharge * Helps organize therapist thoughts * Use for Quality Assurance * Research |
Medical Record & Notes | * Legal Document can be subpoenaed * Never record false info, exaggerate, or make up data * Note about Patient NOT therapist * Concise, use of abbreviations, legible, clear, not vague |
Medical Record & Notes continued... | * Don't use hyphen except with ROM * Semicolon and colon OK * No blank lines between entry * Sign all notes with full name and initials * No "white out" or cross out or blacken anything written (use single line then initial above) |
"S" = Subjective | * Pt. relates hx * Pt tells of lifestyle or home situation * Pt. tells what he/she can no longer do * Voices complaint * States goals * Expresses emotions or response to treatment (Mood, focus, cooperation, energy level, pain level, quotes from Pt & family; "How it feels") |
"S" = Subjective continued... | * Anything the pt expresses (concerns) that is/are relevant to the patient's case or present condition. * Use pt. * Organize subcategories * Quote patient to illustrate point * Can use family member information |
"O" = Objective What went on during treatment. Chronologically if necessary. | * Measurable and observable * Therapist results of measurements * Provides info on what was done with pt on specific date * Important for Reimbursement & legal reasons (must show need for skilled occupational therapy) |
"O" = Objective continued... | * Appropriate terminology * Correct spelling * Organize information so easy to read and understand; flows * Headings based on tests & measurements * Headings based on areas of body |
"O" = Objective COMMON MISTAKES | * Fail to state affected body part * Fail to use measurable terms * Fail to state what is being measured (ex. flexion of Right UE) * BE VERY SPECIFIC |
"A" = Assessment | * Includes everything from "S" and "O" that is not WNL (List of problems) * STG = short term goals * LTG = long term goals * Drawing conclusions & justifying decisions * Identify inconsistencies * Discussion of pt progress in therapy * Suggest further testing, treatment, etc. |
"A" = Assessment continued... | Questions to ask examples: 1. Is pt better/worse today? 2. Did ROM increase/decrease? 3. Is pt showing progress/plateauing? 4. Do you need to rewrite goals? |
"P" = Plan | Plan For Therapy: * Tells time and frequency of therapy ( 60 min per day/ 5 x per week/ 3 weeks) * Tells treatment pt will receive |
Functional Maintenance Program | Program developed for clients discharged from therapy but remain in skilled nursing facility. Program facilitates skills present but not utilized unless compensations or adaptations are provided. |
Informed Consent | Legal and ethical communication process between client and clinician that results in the client's authorization or permission to participate in evaluation and intervention. |
Medical Necessity | Intervention is consistent with the diagnosis, and failure to provide intervention would jeopardize or significantly compromise the client's condition or quality of medical care. |
Negative Prognostic Indicators | Signs that indicate barriers inhibiting rehab potential. |
Positive Prognostic Indicators | Indicators that the client has good rehab potential, which is essential for third-party reimbursement. |
Restorative Programs | Programs that facilitate the learning of new skills in an attempt to "restore" the client's previous abilities. |
Screening | Process of determining if a client requires the skilled services of an OT practitioner. Helps to identify changes in functional status such as improvements or declines in physical or cognitive abilities. |
Standardized Assessments | Methods used for data collection that have established reliability and validity. |
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