What should you document
Client name
Medical record or case number
Name of facility
Name of department
Pertnant info obtain during session
CARE acronym for documenting
Clarity
Accuracy
Relevance
Expectation
How does OTA contribute in the goal writing process?
Providing information about client observations and performance through verbal and written reports to OT
SOAP notes
subjective, objective, assessment, plan
Client reported he was able to undress himself before bed last night "I didn't sleep well"
This is an example of what part of SOAP?
Subjective
Information from intervention, measurements, observable data and quantifiable data: goniometric or strength measurements
This is an example of what SOAP
Objective
Interpretation or analysis of information
Assessment
Estimated duration and frequency of it services and anticipated intervention
Plan
DAP note
Similar to SOAP that S and O are together in the ad section.
Description, assessment, plan
Narrative
Pertinent information in logical order or writers choosing
B.I.R.P. Notes
Behavior of client
Intervention provided
Response to client intervention
Plan for continued intervention
Sometimes in behavioral health setting
PIRP
Purpose or reason for the intervention,
intervention provided,
response of client to intervention,
plan for continued intervention
SIRP
Situation
intervention provided
response of client to intervention,
plan for continued intervention
IEP
Individualized Education Program
School based setting
IFSP
Individualized Family Service Plan. Early intervention settings
Documentation in mental health settings may be ...
Multidisciplinary
MDS
minimum data set. Determine specific level of care needed
SNF, LTC settings
______is the primary payer for OT services in SNF and LTC facilities
Medicare
IRF-PAI
Inpatient Rehabilitation Facility Patient Assessment Instrument by scoring the client on the FIM
OASIS
Home health clients who have Medicare/Medicaid have this completed. Provides guidance for services client requires
HIPPA
Health Insurance Portability and Accountability Act.
-1996 privacy regulations
FERPA
Family Educational Rights and Privacy Act:
1974
Confidentially requirements of students educational records
IDEA
Individuals with Disabilities Education Act
2004
Legislation discusses privacy of information for children with disabilities 0-21
_________may request, review, and audit it practitioners documentation to determine if it meets specific guidelines for reimbursement.
Third party payers (Medicare, Medicaid, private insurance)
Medicare
1965: covers adults 65+, sone people with disabilities younger than 65, end stage renal disease
Medicare Part A
hospital insurance�expenses for inpatient stays, short term stays at SNF, hospice, and some home health. Does not require monthly premium.
Medicare hospital services are paid through __________based on range of services
Prospective payment system (PPS)
Medicare part A cover _______ days in SNF
100. OT is paid as part of the per diem PPS
Psychiatric hospitals are paid for by Medicare under______
IPF-PPS
Person qualified for Medicare part A for _____ of being terminally ill and prognosis fewer than 6 months.
Hospice
Medicare Part B
supplementary medical insurance
Covers cost of outpatient care, some home health, some supplies and equipment.
True or False:
Most people pay a premium each month to cover cost of Medicare part B
True
Medicare part B covers _____ % of cost for medically necessary outpatient PT, OT, ST
Client pays deductible not met and 20% of Medicare costs
80%
T or F
Medicare part B covered OT services are not to exceed a certain dollar amount of "cap" for services.
True
Medicare B generally covers ____% of DME
80%
Client pays remaining 20
What adaptive equipment are not covered by Medicare
Reachers, dressing sticks, bathtub seats, grab bars
Medicare part C
Medicare advantage plan, combo of part a and b. covers all medical services that are needed
Medicare part D
Prescription drug coverage with other coverage such as employer or union health coverage
Federal employee health benefits program
also called the Federal Employee Program (FEP). Covers numerous federal workers
US department of defense health care: TRICARE
Part of military health system, coverage for active duty services members, retirees, families, survivors, certain former spouses.
Medicaid
State and federal.
- Income under certain level, people with disabilities eligible in every state.
- Covers early and periodic screening, diagnosis, and tx for people under 21
- covers services in nursing facilities
CHIP
State children's health insurance program.
Federal and state.
Coverage for children and families with incomes too high to qualify for Medicaid but can't afford private coverage.
IDEA
Individuals with Disabilities Education Act of 1990.
Services to children with disabilities throughout the nation
Idea part B covers
Children and young adults with disabilities age 3-21
IDEA Part C covers
Infants and toddlers age 0-2
Workers compensation
Provider money and medical benefits to employee who has an injury as result of accident
Diagnosis codes are used to:
identify medical necessity
Procedure codes (CPT) are used to:
Denote services they provided for billing
Frequent causes for denial of OT services:
-Experimental intervention,
-writing documentation that does not demonstrate skills of OTR or COTA
-exceeding number of visits allowable
Alternative or integrated delivery systems 3 types:
HMO: health maintenance organization
PPO: preferred provider organization
POS: point of service
HMO
A group plan offering prepaid medical care to its members
PPO
People who belong to it are able to go directly to a specialist without going through primary care physician
POS
Similar to HMO: sometimes allows people to refer themselves to physicians who do not belong to network
Patient Protection and Affordable Care Act
2010: provide greater access to affordable health care insurance
Public health programs
Individuals who lack close proximity to health care or private health care coverage or who are unable to afford private health care, may receive healthcare in a public system
State health programs
Some states have their own health care programs
By 2030 Americans aged 65 and older is estimated to be ____ million
71.5 double what it is now
Management has evolved to a ____ approach
Bottom up
dynamic systems theory
Analysis of systems or organizations that change.
Chaos Theory
Relates to mathematics, how minute changes can cause large outcomes or effects
Complexity theory
knowledge and understanding that transcend linear systems to include a multifaceted worldview
transformational leadership
motivating others to reach highest potential and provide inspiration to others to work effectively to meet goals of organization.
Transactional leadership
Leaders clarify role and task requirements and provide followers with positive and negative regards on successful performance
dyad
in person communication with a second person
What does "Domain" mean in OT domain and process
The focus of occupational therapy
What does "process" mean in OT domain and process?
The delivery of occupational therapy
What areas of occupation are included in the OT framework
ADLs
IADLs
Rest and sleep
Education
Work
Play
Leisure
Social participation
List some methods to establish service competency
Observation or cotreatment
Return demonstration of skills
Review documentation
Testing for knowledge
Discuss cases to assert clinical reasoning and judgement
COTA role in evaluation
- Preforming delegated assessments and delivering reports of observations and client capacities to OTR.
The ______ is responsible for creating the intervention plan. The _____ and _____ partner with client to develop plan.
OTR
OTA & OTA
The _____ is responsible for intervention implementation but may delegate components to the ____ while offering adequate guidance.
OTR, COTA
True or false:
The COTA May measure outcomes and offer clients discharge resources
True
The COTA can contribute to the evaluation process by..
performing delegated assessments and delivering reports of observations and client capacities to OTR