Patient presents to skilled PT following CHF exacerbation with reports of feeling breathlessness with community ambulation. Well! PT developed functional activity tolerance program and instructed patient in NuStep training to increase biofeedback to BLE, mimic reciprocal pattern and increase overall LE strength to decrease abnormal gait pattern. This article is meant to evolve over time, so I’d love to know the types of notes you’d like me to provide in the article. profession of occupational therapy, as well as all payer sources (See references). Occupational therapy documentation provides a record of the practitioner’s ac-tivity in the areas of screening, evaluation and reevaluation, intervention, and outcomes (AOTA, 2014b) in accordance with practice guidelines and payer, facility, and state and federal guidelines and requirements. Keep in mind that there’s really no such thing as a “perfect” OT note, despite what I’m saying in this article. Words and phrases that therapists and assistants should avoid because they often demonstrate lack of skilled care include: • Tolerated well I think as therapists, we tend to document only one part of the story. Care is regarded as “skilled” only if it is at a level of complexity and sophistication that requires the services of a therapist or an assistant supervised by a therapist. Pt instructed in posterior pelvic tilts 3×10 with 3 sec hold. PTM has one of the largest databases of outpatient PT/OT provider productivity, visit and payment information, with more than 3 million visits. See more ideas about pediatric occupational therapy, therapy activities, occupational therapy. OT developed program and patient was instructed in variety of exercises to increase pelvic musculature, reduce urgency and bladder control for overall reduced falls. • Supervising Without PT, patient is at risk for further decline as patient lives alone and was I with all tasks. Patient with difficulty noted for radial/ulnar deviation thus OT stabilized patient at the wrist joint to perform accurately and patient was able to complete with overall less pain. In side lying, patient instructed in 3×10 R hip abduction using 2.5# weights, prone L hip extension, supine single leg raise to patient’s max tolerance. Feb 14, 2018 - Explore Ainsley O'CONNELL's board "OT Documentation", followed by 132 people on Pinterest. PT directed patient x 18 minutes requiring 2 therapeutic rest breaks due to complaints of fatigue and increased respiration. You’re in luck because I have an example for you below! Sutures were removed, and wound is healing well with some edema, surgical glue, and scabbing remaining. Progress to minimal 40 second planks next session but encourage patient to complete to point of fatigue. In the OT Potential Club, which is our OT evidence-based practice club, you can also access our library of documentation examples (we add one each month). Learn vocabulary, terms, and more with flashcards, games, and other study tools. Able to mimic after visual demo with good execution. Occupational therapists and occupational therapy assistants1 determine the appropriate type of documentation structure and then record the services provided within their scope of practice. This research project followed an action research methodology and was guided by a American Journal of Occupational Therapy… Seating professional Occupational Therapists are also seating experts who collaborate with other health care professionals to recommend optimal seating choices for the … STUDY. • Reduced These notes will give you an idea of how a physical therapist might perform documentation for one patient. O2 monitored pre, during and post exercise with O2 levels > 95%. I realize you don’t have the time to read dozens of documentation examples, but I do want to share 4 types of notes that are commonly used in physical therapy. • Compensatory Strategies PT instructed patient in the following exercises to improve functional ROM to facilitate improved gait pattern and reduce falls risk with standing tasks. Patient instructed in piriformis, hamstring stretch x 5 BLE, holding 30 seconds each. Skilled Ot Documentation Snf . Patient required vc and visual demo to perform correctly. With PT direction, patient completed task with symmetrical movement 90% of the time. Patient arrived at OT with R UE weakness s/p CVA. This is almost certainly the case in an evaluation. This section should contain objective measurements, observations, and test results. Left upper extremity: Range of motion within functional limits at all joints and on all planes. I recognize that defensible documentation is an ever-evolving art and science, and have come across many useful resources that will help you keep your notes complete, yet concise. Crystal Gateley and Sherry Borcherding use a “how-to” strategy by breaking up the documentation process into a step-by-step sequence. Patent will increase active range of motion in wrist to within normal limits in order to open and close his laptop and use door handles without increased pain. Using red TB, pt. PT ceased task to reduce and direct program toward pain management. Must identify . Increased time needed due to R hip pain as well as to ensure proper form to prevent injury. Patient then instructed in 30 second planks x 3 with rest breaks in between planks to maximize tolerance. Patient’s Boston Carpal Tunnel Outcomes Questionnaire score will decrease to less than 1.7 on symptoms and function to return to work and social activities without restrictions. You can manage this and all other alerts in My Account. Services will address deficits in the areas of grip strength and range of motion, as well as right hand pain. © 2020 PT Management. Increase of 5 degrees in L hip abduction was achieved through exercises since last reporting period. Flexion:A bending action of a joint or a pulling in of a body part. Apr 30, 2018 - Explore Felicia Bernstein's board "OT Documentation", followed by 240 people on Pinterest. Patient with max cues for posture to reduce trunk sway with standing tasks. Patient was provided education regarding ergonomic setup at work and home, along with home exercise program, including active digital flexor tendon gliding, wrist flexion and extension active range of motion, active thumb opposition, active isolated flexor pollicis longus glide, and passive wrist extension for completion 4-6x/day each day at 5-10 repetitions. ), Functional reporting measures (DASH screen, etc. Decrease OT frequency from 3x/week to 2x/week as tolerated.”. • Stabilized Channel your inner English major. It seems inevitable that our patients will gain easier access to their notes over the next decade, and when they do, I want our documentation to stand out as relevant and useful. • Established Patient instructed in L hip exercises to increase L hip ROM/strength for improved balance and overall pain reduction. Describe why you are providing OT services by stating the relationship between the service and the client's outcomes. OT developed HEP and patient instructed in self ROM/stretches to increase I with HEP for BUE exercises. O2 > 96% when monitored during rest breaks, RR 22 post exercise, 18 at baseline. Then, at the end of the article, you’ll find a sample OT evaluation and some more resources to help you improve your note-writing game. The assessment section is your place to shine! 5. PT facilitated patient in performing activity tolerance task incorporating UE and LE x 5 minutes x 2 trials with rest in between trials. Tactile, verbal and visual cues needed to isolate targeted muscle groups. Patient educated on use of functional activity tolerance training techniques to increase overall pulmonary function. Here are a few things you can generally leave out of your notes: 1. “Patient was seated in chair on a… Able to complete 15 of each exercise prior to modifying task secondary to fatigue. Examples Of Skilled Pt Documentation. Patient instructed in RLE exercises to increase LE strength s/p R knee replacement. occupational therapy documentation - Occupational Therapy Assistant 100 with Marcil at Tidewater … Documentation Manual for Occupational Therapy: Writing SOAP Notes Book Review Merely no words to describe. Words and phrases that therapists and assistants should avoid because they often demonstrate lack of skilled care include: • Tolerated well • Repetitive language (not individualizing sessions/copy feature) • Observing • Supervising • Continue with POC Patient arrived at PT with 4/10 R hip pain. Right upper extremity: Right shoulder, elbow, forearm, digit range of motion all within normal limits on all planes. Flexion/extension—Strength: 4/5, AROM: 50/50, PROM: 60/60, Radial/ulnar deviation—Strength: 4/5, AROM: WNL, PROM: NT, Boston Carpal Tunnel Outcomes Questionnaire (BCTOQ). Patient reported “it feels looser.” Patient verbalized 3/10 pain post session indicating positive results from directed exercises. All of your education and experience should really drive this one paragraph. A quick shout-out: Thank you to The Note Ninjas, Brittany Ferri (an OT clinical reviewer), and Hoangyen Tran (a CHT) for helping me create this resource! • Elicited Documentation Manual for Occupational Therapy: Writing SOAP Notes, Third Edition is designed to provide each part of the documentation … Required max verbal cues, tactile cues and visual demo to reduce compensatory strategies. Occupational function: works a job as a software engineer; begins light-duty work with no typing on 12/20, MD cleared for 4 initial weeks. Details are great, because they help preserve the humanity of our patients, but it’s really not necessary to waste your precious time typing out details like these. Occupational Therapy Assistant Resume. They are intended to be discussion-starters to help us improve our documentation skills. OP Tx Note (diagnosis: post-stroke, self-management tx approach), OT Inpatient Psych Eval (adolescent with suicidal ideation), OT Inpatient Psych Treatment Notes (adolescent with suicidal ideation), School-based OT Eval Report: (diagnosis: autism), Acute Pediatric Tx Note (diagnosis: acute myeloid leukemia), Telehealth School OT Eval Example (diagnosis: trisomy 21), Telehealth School OT Tx Note (diagnosis: trisomy 21), Acute Pediatric OT Eval (diagnosis: acute myeloid leukemia), Inpatient Rehabilitation Eval (diagnosis: ischemic stroke), OP OT Eval (diagnosis: carpal tunnel release), School OT Eval (diagnosis: Down’s Syndrome). Min A provided due to RE weakness and prevention of substitution movements. PT educated patient in B hand strengthening exercises post estim to improve overall grip/pincer grasps. Documentation of occupational therapy services is necessary whenever professional services are pro-vided to a client. Here are a few examples of what you should include: Range of motion measurements (AAROM, AROM, PROM, etc. Patient educated and instructed in R hip exercises to increase R hip ROM/strength for improved balance, pain reduction, as well as core strengthening to reduce compensatory strategies for improved posture. If there aren’t ways to implement these shortcuts, I highly recommend that you request them! While I was creating this blog post, I read every piece of advice I could find on documentation—and I had to chuckle because there was simply no consensus on abbreviations. Must . Where (in your professional opinion) should the patient go from here? Plan to increase intensity when patient feels fully recovered.”, “Patient has been making good progress towards goals, and is eager for more home exercises. • Facilitated Services that do not require the performance or supervision of a therapist are not considered “skilled” even if they are performed by a therapist. PT facilitated patient to complete standing Achilles stretch and seated quad and HS stretch, 3x 30sec each with mod cues for technique and to complete in pain free range for improved gait pattern and maximize ROM. Patient denied shortness of breath and indicated just right challenge. 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