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assessment and
treatment plan
Occupational Performance
Performance areas
Performance components
Performance context
Steps/Stages in Occupation
Therapy process
Clinical Reasoning
Can be defined informally a how we
think about how we do.
Gillette and Mattingly:
Mechanistic: closely allied with the
practice of medicine and address factors
such as how body works biomechanically
Phenomenological: the experience of
being in the world or the life of the
individual as perceived by that person
Teamwork within OT
profession
OTR
COTA
Services to be provided
by personnel who have
demonstrated service
competency
In the interest of
rendering the best care at
the least cost, OTR may
delegate tasks to COTA
Retains final responsibility
for all aspects of care
including doicumentation
Administration of selected
screening instruments or of
assessment such as ROM, ADL
etc
Intervention in the areas of ADL,
work, Play etc
Facilitation of transition
Assistance with the
development of a plan for
discontinuation of service
Contribution to documentation
Education of the patient, family
or community about OT services
OT aides
Teamwork with other professionals
Ethics
Ethics issues confronting in practice:
Cost containment policies that
jeopardized patient care
Inaccurate or inappro. Documentation
Improper or inadequate supervision
Provision of treatment to those not
needing it
Colleagues violating patient
confidentiality
Treatment context
Refers to the environment in which
treatment occurs, an environment
that includes the physical setting and
the social, economic, cultural and
political situation that surrounds it.
Evaluation
Refers to the process of obtaining
and interpreting data necessary for
intervention.
This includes planning for and
documenting the evaluation process
and results.
Assessment
Refers to specific tool or
instruments that are used during the
evaluation process.
Acute rehabilitation
Sub-acute rehabilitation
Skilled nursing facility
Residential care
Home Health
Outpatient
Home and community based therapy
Day treatment
Work site therapy programs
Industrial rehabilitation
Methods of assessment
Medical records
Interview
Observation
Informal
Formal
Assessments
Standardized
Nonstandardized
Treatment Planning
The purpose of Occupational Therapy
is to help learn or relearn essential
occupational performance tasks in the
areas of ADL, work, and play or leisure
that will enable them to live as
independently as possible.
A treatment plan is the design or
proposal for a therapeutic program.
Goals
Objectives: steps towards achieving
goals
Writing Treatment objectives
Terminal behaviour
Conditions
Criterion
Selecting Intervention
Strategies
Implementing the treatment plan
Reevaluating the patient and the
Treatment plan
Revising the treatment plan
Discharge planning
Terminating treatment
Documentation
Purposes of documentation:
It facilitates effective treatment
It justifies reimbursement
It stands as a legal document
It provides communication among the
patient, the treatment team and the family
Guidelines for
documentation
Therapist should consider the
audience for which documentation is
intended.
Important to consider who will read
this documentation and who will
benefit from it.
Depend on the setting, the consumer,
the payer, and other providers.
Guidelines for
documentation
RUMBA test
Was originated by AOTA in the 1070s
as a method used in quality
assurance.
Has developed further to be used as
a method of self assessment not only
in quality assurance but also in
documentation, intervention, and
research.
R= Is it Relevant?
U= Is it Understandable?
M=Is it Measurable?
B= Is it Behavioural?
A= Is it Achievable?
R= Is it Relevant?
Reports should reflect functional
goals and achievements because
these indicate the true relevance of
intervention.
Is it Understandable?
Several dos and dont for the documentation.
Must be readable and therefore writing must be
legible.
Jargon should be avoided
Sentences should be concise, succinct, and
constructed using proper grammar and spelling.
Contrary to early professional standards in
documentation, it is becoming more acceptable to use
the first person in sentence structure; that is this
therapist applied or I have determined.
Don not use noncommittal language; that is it
seeems or it appears that.
M=Is it Measurable?
Goals and statements should be used
in measureable terms.
Other professionals can understand
the measures being used.
Measurements should be in terms of
frequency and duration etc.
Is it Behavioural?
Otists are trained to be fine
observers of behaviour.
Behaviours are those occurrences
that are seen and can be measured.
The words friendly, depressed,
appropriate and unmotivated do not
describe behaviour.
Is it Achievable?
At this step, Otist should try to step outside the
situation and look at the goal statements from
the perspective of the reimburser or accreditor.
The Question is: Is this plan or goal achievable
for this person, given the time constraints
imposed by reimbursement or regulatory
standards? If answer is no then the goal is not
realistic, given the treatment setting and
constraints, and the documentation should be
reworked.
SOAP
This format may be used for initial
notes, interim or progress notes and
discharge notes.
Under POMR system, service notes are
not written; instead, members of the
treatment team write SOAP notes to
address those problems that are
appropriate to their interventions.
Uniform Terminology
The use of standardized UT can assist in
avoiding disparity in the types of coverage
from one region to another.
It facilitates review for reimbursement in that
reviewers are accustomed to the
terminology.
Can impact on standards, reimbursement,
management and research.
Classification codes
International Classification of
Impairments, Disabilities, and
Handicaps
Hospitals
Community agencies
Residential agencies
Schools: Individual Education
Program (IEP)
Computerized
Documentation