Mar 29, 2024  
College Catalog 2021-2022 
    
College Catalog 2021-2022 [ARCHIVED CATALOG]

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OTAS 2402 - Skills for Occupational Therapy Documentation II

Credit Hours: 1.50
Prerequisites: Admission into the Occupational Therapy Assistant Program; OTAS 1300 , OTAS 1351 , OTAS 1361 , OTAS 1370 , OTAS 1401 , OTAS 1420 , and OTAS 1450  all with grade C or better

Corequisites: OTAS 2095 , OTAS 2350 , OTAS 2370 , OTAS 2410 , OTAS 2425 , and OTAS 2450  

Building upon the skills and knowledge acquired in OTAS 1401 - Skills for Occupational Therapy Documentation I, this lab-based course instructs the student in further development of competency-based application of documentation principles and skills. Adherence to AOTA guidelines, state licensure law and public health code, third-party reimbursement guidelines, regulations, appeals, confidentiality and the Health Insurance Portability and Accountability Act (HIPAA), screening and evaluation, intervention plans, long- and short-term goals/objectives, intervention notes, and discontinuation summaries will be applied to actual client intervention sessions. The emphasis of this course focuses on the application of observation, clinical reasoning, and demonstration of skilled competency in documentation.

Billable Contact Hours: 3

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OUTCOMES AND OBJECTIVES
Upon completion of this course, the student will be able to demonstrate acquired competency through:

  1. Competent analysis and application of documentation guidelines and formats.
    1. Analyze and demonstrate competency in documentation content.
    2. Apply knowledge of the legal implications of documentation.
    3. Apply knowledge of third-party payer guidelines and state regulations.
    4. Apply knowledge of medical record formats.
    5. Apply knowledge of approved abbreviations and professional terminology.
    6. Apply confidentiality/HIPAA regulations and demonstrate the consequences of breaching the guidelines and principles.
    7. Identify and demonstrate documentation formats into electronic medical records.
    8. Apply knowledge of skilled OT service criteria with documentation of intervention.
  2. A competent basic analysis and application in OT documentation and formats.
    1. Apply observation to OT documentation.
    2. Apply clinical reasoning to OT documentation, utilizing the OT practice framework.
    3. Apply competency in basic interpretation of OT evaluation results to establish functional problem statements with intervention planning, progress notes and discontinuation summaries.
    4. Apply the use of approved abbreviations and accepted and legal professional terminology in documentation.
    5. Apply methods of correcting documentation.
    6. Relate the components of OT evaluations and commonly used assessment tools in documentation.
    7. Relate knowledge in the application of the components of OT intervention plans.
    8. Relate knowledge in the application of the components of long-term goals writing.
    9. Relate knowledge and apply the components of short-term goals or objective writing.
    10. Relate knowledge and correctly apply the components of SOAP notes writing.
    11. Relate knowledge and correctly apply the components of narrative notes writing.
    12. Relate knowledge and correctly apply the components of discontinuation summary writing.
    13. Relate knowledge in the analyzing and application of the role of the OT/OTA in OT documentation.
  3. Competent adherence to reimbursement guidelines and regulations for reimbursement of OT services.
    1. Demonstrate correct application in the documentation of skilled OT services, adhering to reimbursement guidelines.
    2. Demonstrate knowledge and competency with the Medicare review process, the appeals and reconsideration process and the implications to OT practice.

COMMON DEGREE OUTCOMES (CDO)
• Communication: The graduate can communicate effectively for the intended purpose and audience.
• Critical Thinking: The graduate can make informed decisions after analyzing information or evidence related to the issue.
• Global Literacy: The graduate can analyze human behavior or experiences through cultural, social, political, or economic perspectives.
• Information Literacy: The graduate can responsibly use information gathered from a variety of formats in order to complete a task.
• Quantitative Reasoning: The graduate can apply quantitative methods or evidence to solve problems or make judgments.
• Scientific Literacy: The graduate can produce or interpret scientific information presented in a variety of formats.

CDO marked YES apply to this course:
Communication: YES
Critical Thinking: YES
Scientific Literacy: YES

COURSE CONTENT OUTLINE
 

  1. Review of the Basics
    1. Documentation
      1. Types of documentation and its purpose
    2. Legal document implications
      1. Descriptive vs interpretive statements
      2. Documenting for court
    3. Acceptable way to correct errors in a legal document
    4. Confidentiality with medical records and information
      1. HIPAA
      2. State licensure law and public health code
      3. Facility
      4. Departmental and inter-professional team
    5. Documenting the distinct value of OT intervention
      1. Skilled versus unskilled intervention
  2. Review of OT/OTA Responsibilities
    1. Roles of OT/OTA with documentation
    2. AOTA guidelines regarding documentation for OT/OTA
    3. Requirements and guidelines of third-party payers
    4. Credentials and signatures in documentation
    5. Variety of settings and responsibilities
  3. Analyzing use of Professional Terminology
    1. Professional terminology and accepted abbreviations when completing documentation assignments
    2. Applying the OT practice framework terminology and its distinct application to skilled OT services in documentation
    3. Identifying, formulating and applying occupational therapy problems
      1. Application of the OTPF and correct terminology
  4. Problem Oriented Medical Record (POMR)
    1. SOAP format
    2. Narrative format
    3. Application of clinical reasoning
  5. Application of Activity Analysis and Observation Skills into OT Documentation
    1. Gathering and utilizing client information from the medical record and the OT evaluation to establish functional problem statements, goals and document client performance
    2. Applying observation skills in accurate documentation of performance in objective terms
    3. Applying activity analysis to synthesis intervention and performance data to intervention documentation
    4. Applying clinical reasoning skills to substantiate medical necessity through professional assessment and documentation
    5. Documentation of skilled services versus non-skilled services
      1. Professional assessment
      2. Substantiation of services
      3. Reasonable and medically necessary intervention
  6. Application of Functional OT Goals/Performance Objectives
    1. Application and documentation of functional long and short-term occupational therapy goals
    2. Application and documentation of performance objectives which includes the instructional variable, observable behavior, measurement and proficiency.
  7. Developing, Documenting and Interpreting an Intervention Plan
    1. Documenting intervention plans with focus on function and OTPF
    2. De-emphasizing the methods and modalities
      1. Applying function to the intervention and documentation of the client’s response to intervention
  8. Documentation in Narrative Format
    1. Progress and discharge note using the narrative format
    2. Applying clinical reasoning, client response and professional assessment
  9. Documenting in SOAP Format
    1. Progress and discharge note using the SOAP format
    2. Applying clinical reasoning, client response and professional assessment
  10. Reconsideration and Appeals Process
    1. Denial/appeals process
    2. Implications to reimbursement
    3. Types of appeal letters
  11. Identifying and Applying Required Documentation Content to a Variety of Documentation Formats
  12. Electronic Medical Records and Documentation / Incorporating Documentation Content into the EMR

Primary Faculty
Seefried, Mariea
Secondary Faculty
Wysocki, Pennie
Associate Dean
Primeau, Paula
Dean
Mirijanian, Narine



Official Course Syllabus - Macomb Community College, 14500 E 12 Mile Road, Warren, MI 48088



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