OTAS 1401 - Skills for Occupational Therapy Documentation I-Lab

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.

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