Occupational Therapy Progress Note - Documentation Guide

Justification For Skilled Services
Skilled services required to: In order to:
Improve Independence with ADL's Ensure safe return to private residence/community/ACLF
Increase Safety awareness Perform functional transfers without any physical support or assistive devices
Maximize Rehab potential Perform ADL's with increased safety
Modify Restorative nursing program Ensure good follow through
Develop/implement Motor control/tone in UE Improve functional use of UE in ADL performance
Facilitate ROM Be completely independent without supervision
Assess/complete Strength Decrease risk for falls
Teach compensatory strategies Postural alignment Decrease pain in UE for safe completion of ADL's
Minimize Static & dynamic sitting & standing Decrease incontinent episodes and use of adult protective undergarments
Train caregivers Activity tolerance Use adaptive equipment for performance of safe ADL's
Promote Coordination deficit Return to prior level of function
Restore Orthotic device To feed self and perform UB ADL's with increased independence
Complaint of pain
Urinary continence
Cognitive abilities
Home evaluations
Environmental hazards
Discharge planning

Medical Necessity Referance CMS 100.2 Chapter 8, Section 30
Services are directly and specifically related to an active written treatment plan established by the physician in consultation with OT and are reasonable and necessary to the treatment of the individual's illness or injury.

Services are at a level of complexity and sophistication or the condition of the patient must be of a nature that requires the judgement, knowledge, and skills of a qualified OT.

Services are skilled when the condition of the patient will improve in a reasonable and generally predictable period or the services are necessary for the establishment of a safe and effective maintenance program.

The services must be considered under accepted standards of medical practice to be specific and effective treatment for the patient's condition.

Services may be considered skilled in cases in which, the special medical complications require skilled OT to perform or supervise it or to observe the patient/resident.

Services are skilled when management and evaluation of a patient/resident's care plan, based on physician's orders, requires the involvement of OT to meet the patient/resident's medical needs, promote recovery, and ensure medical safety.

The patient requires observation and assessment to identify and evaluate the patient's needs for possible modification of treatment or initiation of additional medical procedures until the patient's treatment regimen is stabilized.

The patient requires teaching and training activities to manage his/her treatment regimen by skilled OT personnel.
You must document the continued medical necessity for skilled OT.

Please note the examples below require additional patient specific information.

Example - Continued skilled OT is required to develop a home exercise program to improve UE strength and teach and train the patient and family in the exercises as well as home safety.

Example - Continued skilled OT is required to design a restorative feeding program and in-service the nursing staff.

Example - Continued skilled OT is required for ultrasound to right shoulder for pain, and strengthening exercises to right UE to improve ability to bath and dress UB with decreased assistance. Patient is reporting 5 on a pain scale of 0-10 and requires moderated assistance to bath and dress UB.

Did you address?
- All the functional areas and STG's from the evaluation. Also, functional areas that were addressed for last week, current week and STG's have been listed with a projected date. Did you include time frames for achievement of all goals?

- Use of comparative statements from week to week in the summary of significant progress towards the goals. Are your goals functional and measurable?

- BUE strength, ROM in BUE, which limits functions of ADL's.

- Hand functions, muscle tone, motor/coordination, edema in UE, pain in UE, use of splints/braces to prevent contractures.

- Ability to perform ADL's using adaptive equipment.

- Use of walker, grab rails, raised toilet commode seat, LB dressing adaptive equipment i.e. shoe horn, reacher, dressing stick, sock aid, elastic shoe laces, adaptive eating devices, use of adult protective undergarments for UI.

- Activity tolerance and endurance with ADL's.

- Dynamic and static standing and sitting balance required for ADL's, safety awareness.

- Weight bearing status with functional transfers.

- Compensatory strategies to increase independence with ADL's.

- Patient will demonstrate improvement in attention span, learning new safety awareness techniques while performing ADL's.

- Reduce perseveration and impulsivity by decreasing complexity and speed of verbal/visual cues and instructions. Reduce impulsivity by encouraging the resident to state the steps involved in each activity.

- Improve memory impairment with ADL tasks by establishing structured schedule and adhere to it. Provide same routine in ADL's and consistent approach in therapies.

- Improve perception: visual-spatial awareness, body integration, body image and scheme, spatial relations, figure ground discrimination and apraxia.

- Time frame required to achieve goal & measurable level of improvement expected in each area in given time.

- Caregiver education, family education, home evaluation, develop restorative nursing program.

Teaching and Training
Did you include?

- Who was trained: Restorative aides, maintenance aides, family, and patient/care-givers?

- Method of training: demonstration with adaptive equipment splints, positioning equipment, verbal or visual presentation.

- Response to training and evidence of comprehension of matter presented (return demonstration completed by the person trained, regarding ROM exercises, pelvic muscle exercises for urinary incontinence, management of UE pain, use of adaptive equipment, splints, positioning equipment and balance exercises.)

Potential For Achieving Goals
Did you list reasons why potential was excellent or good?

- Patient had good prior level of function.

- Patient follows directions very well. Patient has good cognition.

- Patient participates well with the treatment plan.

- Patient demonstrates good progress when previously seen by therapy, prior to hospitalization.

- Good family support and involvement with the therapy treatment plan.

- Risk for falls, cardiac precautions, cardiac pacemaker, weight-bearing status, decreased safety awareness, respiratory precautions, use of O2, risk for developing contractures and skin breakdown, risk for aspiration, weight loss, NPO status, diet restrictions, code status, confusion, visual/hearing impairment.

Changes With The Treatment Plan
- Patient could not meet the established goals therefore goals were modified.

- Patients weight-bearing status changed therefore goals were upgraded.

- Patient experienced a medical decline; therefore, new goals were formulated.

- Patient was medically unstable therefore patient was placed on medical hold.

- Patient achieved targeted LTG's therefore goals were up graded/modified.

- Assessment or reevaluation indicated a change in status.

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