Guidelines for Documentation of Occupational Therapy

• Published in: The American journal of occupational therapy 2018-11, Vol.72 (Supplement_2), p.7212410010p1-7212410010p7
• Main Author: Kearney, Kimberly
• Format: Article
• Language: English
• Subjects: Accreditation (Institutions); Analysis; Associations; Caregivers; Codes; Confidentiality; Critical incidents; Documentation; Guidelines; Health Conditions; Health Needs; Identification; Intervention; Laws; Medicaid; Medical personnel; Medical records; Medicare; Occupational therapy; Organizational change; Outcome Measures; Practice; Practice guidelines (Medicine); Professional training; Profiles; Referral; Regulation; Self report; State laws; Terminology; Therapists
• ISSN: 0272-9490; 1943-7676
• DOI: 10.5014/ajot.2018.72S203

Formal reevaluation is conducted when, in the professional judgment of the occupational therapist, new clinical findings emerge, a significant change in the patient's condition requiring further tests and measures is observed, the client demonstrates a lack of response as expected in the plan of care, or additional information is required for discharge (CMS, 2017b) or when required by practice guidelines and payer, facility, and state and federal guidelines and requirements. Content includes date, length of service contact, type of contact, names and positions of persons involved, summary of significant information communicated during contact, client attendance and participation in intervention or reason service was missed, types and approaches of interventions used, client's self-report and response to intervention, adverse reaction or response to treatment, environmental or task modification, assistive or adaptive devices used or fabricated, statement of any training education or consultation provided, and client's present level of performance. C. Summary of services provided-Brief statement of frequency and duration of services, types and approaches of interventions provided; data collection procedures (age-appropriate standardized and nonstandardized assessments, tests, and measures) and results; measurable progress (or lack thereof); environmental or task modifications provided; adaptive equipment or orthotics provided; medical, educational, or other pertinent client updates; client's response to occupational therapy services; and programs or training provided to the client or caregivers. Fundamentals of Documentation * Documentation practices and storage and disposal of documentation must meet all state and federal regulations and guidelines, payer and facility requirements, practice guidelines, and confidentiality requirements. * Client's full name, date of birth, gender, and case number, if applicable, are included on each page of the documentation. * dentification of type of documentation and the date service is provided and documentation is completed are included in the documentation. * Acceptable terminology, acronyms, and abbreviations are defined and used within the boundaries of the setting. * Clear rationale for the purpose, value, and necessity of skilled occupational therapy services is provided.