OT 105 - Documentation in Occupational Therapy

1. Identify the professional, ethical, and legal requirements in clinical documentation required to meet standards for reimbursement of services (2023 ACOTE Standards B.4.4 and B.4.8).
2. Explain the role delineation and responsibilities of  the OT and OTA for documentation in various practice settings (2023 ACOTE Standards B.4.3 and B.4.9 and B.3.17).
3. Apply commonly used abbreviations and OT terminology in documentation of services in the health record.
4. Differentiate between an initial evaluation, progress note, contact note, and discharge summary.
5. Demonstrate the ability to develop treatment objectives, goals, and interventions to meet standards of skilled care (2023 ACOTE Standard B.3.2).
6. Define and demonstrate writing the four components of the SOAP note (“S”-Subjective, “O”-Objective, “A”-Assessment, and “P”-Plan). 
7. Contrast various styles of documentation including SOAP and narrative formats .
8. Define and demonstrate knowledge of electronic health record (EHR) or electronic medical record (EMR) (2023 ACOTE Standard B.3.18).
9. Demonstrate knowledge of various reimbursement systems and funding mechanisms treatment/diagnosis codes, and coding and documentation requirements that affect consumers and the practice of occupational therapy (2023 ACOTE Standard B.4.3).
10.  Documentation effectively communicates the need and rationale for skilled occupational therapy services (2023 ACOTE Standard B.4.3).

A. Process

B. Occupational Therapy Practice Framework

C. Occupational Profile

II. Use of Language

A. Common Abbreviations

B. OT Terminology and Assessment Scales

C. Types of Clinical Notes

D. General Mechanics of Documentation

E. Corrective Procedures

III. Ethical and Legal Considerations

A. Skilled Care

B. Reasonable and Necessary Care

C. Confidentiality and Records (HIPPA)

D. Role Delineation OT and OTA

E. Current Standards

IV. Treatment Planning

A. Writing Objective

B. Writing Goals

C. Writing Interventions

V. Clinical Documentation

A. Acronym SOAP Note

B. “S”–Subjective component of the SOAP Note

C. “O”-Objective Component of the SOAP Note

D. “A”–Assessment Component of the SOAP Note

E. ”P”–Plan component of the SOAP Note

VI. Contrast of  Documentation Methods

A. SOAP Format

B. Narrative Format

C. Documenation aross Practice Settings

D. Electronic Medical Records/Electronic Health Records

Facilitated practice: 30-40%

Demonstration: 30-40%

 
Mandatory Course Components:
None
Equivalent Courses:
None