DOCUMENTATION

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created 5 years ago by leslieann_benegasi
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1

TYPES OF NOTES (6)

Initial Evaluation Report
Contact Notes
Progress Report
Reevaluation Report
Transition Plan
Discharge or Discontinuation Report

2

HEALTH RECORD

Medical record” now referred to as “health record”
Is a legal document; also includes documentation in school-based settings
Primary purpose is the exchange of information, develop an appropriate plan, record treatment, facilitate continuity of care upon d/c, and fulfill legal documentation requirements
Shift from paper notes to electronic health record (EHR) or electronic medical record (EMR)
Many different software programs available, depending on practice setting
Providers reimbursed by Medicare and Medicaid MUST use certified EHR technology in order to meet specific requirements for security and functionality

3

BENEFITS OF ELECTRONIC DOCUMENTATION

EHRs help standardize, streamline, and organize information
Typically includes use of check-offs or prompts to meet requirements
Helps facilitate reporting outcome measures used in different settings
Allows timely sending/receiving of health information throughout departments
Many people can review information at the same time in various locations
Typically password-protected

4

ELECTRONIC DOCUMENTATION CONS

Staff must be trained which is time consuming; many “old school” therapists may have some resistance
Takes additional documentation time which may affect productivity
OT practitioners may have to share computers
Concerns regarding privacy, “crashes”, computer downtime
Information may be accidentally destroyed or entered inaccurately
Devices containing sensitive information on hard drives or discs could be lost or stolen
Some practitioners may fall into rote or cookbook approach

5

HIPPA

Health Insurance Portability and Accountability Act
Delineates an individual’s right to understand and control the use of one’s own health information and also be informed about a provider’s privacy practices, including how one’s information will be used and shared
Protected health information (PHI)
Covered entity; OT practitioners come under this category and must adhere to HIPAA regulations
Minimum necessary standard

6

HIPPA CONTD

OT practitioners are not permitted to disclose any information about your client’s condition with any person not involved in medical care without client’s permission
Not permissible to look up information on a friend, colleague, neighbor’s mother, etc…
“Working files” may be kept as long as information is stored in a locked cabinet and is shredded when no longer needed
Take home message….
IT IS ESSENTIAL THAT YOU DO NOT DISCLOSE OR GIVE OUT ANY HEALTH RECORDS OR CLIENT INFORMATION WITHOUT FULLY UNDERSTANDING THE LAW AND KNOWING THE FACILITY’S POLICY AND PROCEDURES

7

FERPA

Family Educational Rights and Privacy Act
Outlines a student’s rights and privacy regarding his or her education records
If as an OTA working in a school-related setting, it is essential that you do not disclose or give out any student records without fully understanding the law

8

SOAP NOTES

Developed by Dr. Lawrence Weed in the 1960’s
Outline for organizing information
Four distinct sections:
Subjective
Objective
Assessment
Plan

9

NARRATIVE NOTES

Typically written in less restricted paragraph format
Must be careful that all pertinent information is included

10

RULES OF DOCUMENTING

Use black ink that is waterproof and noneraseable.
NEVER use correction fluid or correction tape.
Correct errors properly:
Patient able to don upper body clothing with mod assist min verbal cues to maintain sternal precautions jwc 9/5/14
Do not erase.
Do not leave blank spaces or lines.
Be sure all required data are present.
Write legibly, type carefully, and enter all information accurately.
Use people first language.
The OTA should not be referred to as “therapist.”