Mar 29, 2024  
College Catalog 2022-2023 
    
College Catalog 2022-2023 [ARCHIVED CATALOG]

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OTAS 1401 - Skills for Occupational Therapy Documentation I-Lab

Credit Hours: 1.50
Prerequisites: Admission into the Occupational Therapy Assistant Program; OTAS 1000 OTAS 1012 , OTAS 1110 , OTAS 1210 , OTAS 1230 , and OTAS 1235  all with grade C or better

Corequisites: OTAS 1300 , OTAS 1351 , OTAS 1361 , OTAS 1370 , and OTAS 1420 

This lab‑based course introduces the student to the basic concepts of documentation and note writing skills for the occupational therapy assistant. The course will explore various documentation formats, electronic medical records, AOTA guidelines, state licensure law and public health code, third‑party reimbursement guidelines and regulations, confidentiality, and the Health Insurance Portability and Accountability Act (HIPAA). Client case studies will be utilized to gain knowledge in OT evaluations, intervention plans, long‑ and short‑term goals/objectives, intervention notes, and discontinuation summaries. Problem Oriented Medical Record (POMR) will be introduced, and intervention note formats will be presented utilizing the OT practice framework. This course focuses on competency‑based learning and clinical reasoning for the purpose of identifying OT problems, goals, interventions, and outcomes.

Billable Contact Hours: 3

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Transfer Possibilities
Michigan Transfer Network (MiTransfer) - Utilize this website to easily search how your credits transfer to colleges and universities.
OUTCOMES AND OBJECTIVES
Upon completion of this course, the student will be able to demonstrate acquired competency through:

  1. Interpretation of documentation guidelines and formats.
    1. Identify and explain the purpose and types of documentation.
    2. Identify and explain the legal implications of documentation.
    3. Identify and explain third‐party payer guidelines and state regulations.
    4. Identify and explain medical record formats.
    5. Identify and explain standard medical abbreviations.
    6. Identify and explain professional terminology.
    7. Identify and apply the concept of confidentiality and HIPAA regulations, including consequences of breaching in fieldwork and as an OT practitioner.
    8. Explain the use of electronic medical record.
    9. Identify and explain how to substantiate skilled OT service.
  2. Utilization of Basic skill of OT documentation and documentation formats.
    1. Identify and apply observation to OT documentation.
    2. Identify and apply clinical reasoning to OT documentation.
    3. Identify and apply the OT practice framework to documentation.
    4. Identify and demonstrate the difference between an OT evaluation, intervention plans, intervention notes and discontinuation summaries.
    5. Identify and apply professional terminology and approved abbreviations in documentation.
    6. Identify and apply methods of correcting legal documentation.
    7. Identify, gather and utilize the components of OT evaluations.
    8. Identify and complete the components of OT intervention plans.
    9. Identify and complete the components of long‐term goals.
    10. Identify and document short‐term goals or objectives.
    11. Identify and document the components of SOAP notes.
    12. Identify and document the components of narrative notes.
    13. Identify and document the components of discontinuation summaries.
    14. Identify and explain the collaborative role of the OT/OTA in documentation.
  3. Utilization and incorporation of activity analysis and observation skills into OTA documentation.
    1. Gather and utilize client information from the medical record and the OT evaluation to demonstrate accurate documentation of client performance.
    2. Utilize observation skills in accurate documentation of performance in objective terms.
    3. Utilize activity analysis to synthesis intervention and performance data to intervention documentation.
    4. Utilize basic clinical reasoning skills to substantiate medical necessity through professional assessment and documentation.

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. Introduction to Occupational Therapy Documentation
    1. A basic skill competency of the profession
    2. Changing healthcare environment
    3. Why OT must substantiate intervention
    4. Skill versus unskilled intervention
      1. Documenting utilizing the OT practice framework
      2. Client factors affecting ability to perform occupational activities
      3. Objective and measurable documentation
  2. Documentation - Purpose and Types
    1. Types of documentation and its purpose
      1. Problem oriented medical record (POMR)
        1. Explain the history and philosophy of POMR
      2. Source oriented medical record
      3. Documentation formats
        1. Electronic medical record
        2. Flow charts
  3. Documentation Legal Basics
    1. Implication legal document
    2. Writing with a jury in mind
    3. Descriptive vs interpretive statements
    4. Correcting errors in a legal document
      1. Acceptable way to correct errors in a legal document
    5. Credentials
      1. Understand state and federal laws and regulations and the application to documentation
  4. Confidentiality
    1. Demonstrate understanding of confidentiality with medical records and information
    2. HIPAA regulations and its’ implications to documentation and the OT practitioner
  5. OT/OTA Responsibilities
    1. Differentiate between roles of OT/OTA in documentation
    2. Identify AOTA guidelines for documentation
    3. Identify basic requirements of third‐party payers
    4. Understanding third‐party payer guidelines and settings
      1. Hospitals
      2. Community agencies
      3. Residential agencies
      4. Schools
  6. Essential Elements of Guidelines
    1. Who is the audience
    2. Is it relevant
    3. Is it understandable
    4. Measurable
    5. Behavioral
    6. Achievable
  7. Problem Oriented Medical Record (POMR)
    1. SOAP notes
    2. Narrative notes
    3. Clinical reasoning process
  8. Utilizing and Incorporating Activity Analysis and Observation Skills into OT Documentation
    1. Gathering and utilizing client information from the medical record and the OT evaluation to document client performance
    2. Utilizing observation skills in accurate documentation of performance in objective terms
    3. Utilizing activity analysis to synthesis intervention and performance data to intervention documentation
    4. Utilizing basic clinical reasoning skills to substantiate medical necessity through professional assessment and documentation
  9. Writing Functional OT Goals
    1. The need for goals
    2. Elements of goal writing
    3. Beginning skill in writing functional long‐term occupational therapy goals
    4. Beginning skill in writing performance objectives/short‐term goals
      1. Instructional variable
      2. Observable behavior
      3. Measurement
      4. Proficiency
  10. Developing an Intervention Plan
    1. Basic intervention plan components
      1. Functional problem statement
        1. Bases on areas of occupational performance
    2. OT goals
    3. Methods and modalities of intervention
    4. Clinical reasoning
  11. Narrative Format
    1. Intervention notes, progress summaries and discontinuation summaries utilizing the narrative format
  12. SOAP Format
    1. Intervention notes, progress summaries and discontinuation summaries utilizing the SOAP format
  13. Skilled Services vs Non‐skilled Services
    1. Professional assessment
    2. Substantiation of services
    3. Reasonable and medically necessary intervention
  14. Professional Terminology
    1. Utilization and identification of professional terminology and approved abbreviations when completing documentation assignments
  15. Electronic Medical Record
    1. Use of computers as a documentation tool
    2. Advantages and challenges of electronic medical records

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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