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Clinical Documentation - Occupational Therapist


Documentation 210

Documentation of Occupational Therapy Services


2.0

$38.00 USD

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  • Identify five purposes of documentation
  • Describe the basic technical points that should be adhered to when writing in the medical record
  • Explain why only approved abbreviations should be used in occupational therapy documentation
  • Describe the acceptable method of correcting an error in the medical record
  • Explain why occupational therapy documentation should reflect the terminology outlined in the Occupational Therapy Practice Framework
  • Describe the components of a well-written progress note
  • Identify the different places where documentation is required
  • Briefly summarize the content of the initial evaluation
  • Define assessments as they apply to the occupational therapy process
  • Describe the purpose of the intervention plan
  • Explain why establishment of goals should be a collaborative effort between the client and the therapist

Joanne Brown, MS, OT, CHT

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Documentation 209

Documenting the Assessment: Summary and Diagnosis


1.0

$19.00 USD

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  • Explain the role of physical therapists in establishing and documenting a diagnosis
  • Describe the elements of the Assessment section of an evaluation report
  • Appropriately document an Assessment for different case scenarios

Joanne Brown, MS, OT, CHT

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Documentation 208
Documenting Impairments in Body Structure and Function

1.0

$19.00 USD

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  • Define impairments in body structure and function
  • Appropriately classify impairments into categories for documentation purposes
  • Document impairments concisely using appropriate terminology and abbreviations
  • Describe documentation of a systems review
  • Describe the seven characteristics of documenting pain

Joanne Brown, MS, OT, CHT

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Documentation 207

Documenting Activities


1.0

$19.00 USD

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  • Define activities and function
  • Discuss the factors involved in deciding which activities should be included in physical therapy documentation, including consideration of benchmark activities
  • Identify and classify various aspects of documenting activities
  • Appropriately categorize activities of daily living and instrumental activities of daily living
  • Document activities using a skill-based framework

Joanne Brown, MS, OT, CHT

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Documentation 206

Documenting Reason for Referral: Participation and Social History


1.0

$19.00 USD

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  • Describe the components of documenting participation, social history, and general health status
  • Describe the usefulness of standardized outcome measures for documenting participation
  • Describe the process of conducting an interview to obtain information pertaining to level of participation, social history, and general health status
  • Document these components with accuracy and specificity
  • Read and analyze clinical examples emphasized with case examples

Joanne Brown, MS, OT, CHT

Case Studies
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Documentation 205
Documenting Reason for Referral: Health Condition and Participation

1.0

$19.00 USD

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  • Identify and classify various aspects of documenting reason for referral, including a patient’s background information, health condition, medications, past medical history, social history/participation, and prior functional status
  • Explain the 3 key elements of describing a patient's current health condition
  • Discuss the implications of direct access for documenting medical diagnoses
  • Describe the process of conducting an interview to obtain information pertaining to gathering history data
  • Appropriately document elements of reason for referral based on case scenarios

Joanne Brown, MS, OT, CHT

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Documentation 204

Documentation in Pediatrics


1.0

$19.00 USD

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  • Describe the laws governing documentation in early intervention and school-based settings in the United States
  • Identify commonly used standardized assessments in early intervention and school-based settings
  • Document components of early intervention evaluations and session notes, which are family-centered, child-specific, routines-based, and aligned with the natural environment
  • Document components of school-based evaluations and session notes, which are child-centered and specific to the school setting
  • Create goals for a pediatric client based on best practice standards, including making goals child-centered, context-specific and addressing specific tasks or functional activities

Joanne Brown, MS, OT, CHT

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Documentation 203

Documenting the Plan of Care


1.0

$19.00 USD

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  • Identify and describe the components of documentation of the plan of care
  • Appropriately document a plan of care as part of an initial evaluation
  • Discuss the importance of documenting informed consent

Joanne Brown, MS, OT, CHT

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Documentation 202
Developing and Documenting Effective Goals

1.0

$19.00 USD

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  • Differentiate between goals and outcomes
  • Describe the important aspects of writing goals at the participation, activity, and impairment levels
  • Distinguish between short-term and long-term goals
  • Describe the essential components of a well-written functional goal Identify poorly written goals and make modifications to goals
  • Appropriately document participation and activity goals for a written report

Joanne Brown, MS, OT, CHT

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Documentation 201

Payment Policy and Coding


1.0

$19.00 USD

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  • Provide a brief overview of health care reform and its impact on physical therapy and third-party payers in context of reform environment
  • Describe Medicare settings that outpatient services are provided in, as well as the characteristic policies and key compliance elements required by Medicare and other third-party payers
  • Outline Medicare guidelines for documenting skilled therapy services
  • List the components of documentation for Medicare, including initial evaluations including plan of care, progress notes, session notes, reevaluations, and discharge summaries
  • Understand basics of functional limitation reporting, physician quality reporting system and diagnosis coding and CPT coding for billing and payment purposes
  • Summarize guidelines for CPT coding that may facilitate payment for services and minimize payment delays and denials

Joanne Brown, MS, OT, CHT

Downloadable Course in PDF
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