7. 2. • Modified Patient required mod vc with visual demo to execute properly to avoid injury. The Note Ninjas was founded by Nicole Trubin, MS, OTR/L and Stephanie Mayer, PT, DPT. Progress to minimal 40 second planks next session but encourage patient to complete to point of fatigue. 14. In supine, patient instructed in R hip abd/add, flex/ext, bridging 3×10 with tactile guiding due to weakness. 6. PT instructed patient in variety of core strengthening exercises to decrease complaints of back pain. Occupational therapists and occupational therapy assistants1 determine the appropriate type of documentation structure and then record the services provided within their scope of practice. 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. Patient stated, “wow I’m really out of shape,” but with education on energy conservation techniques, was able to complete the task. In every good story, there’s a hero and a guide. © 2020 PT Management. Prior level of functioning: independent in work duties, activities of daily living, and instrumental activities of daily living. Occupational therapy documentation. • Continue with POC. to therapy or treatment. Plan to add additional stability work at next visit.”. • Patient is at risk for… Seating professional Occupational Therapists are also seating experts who collaborate with other health care professionals to recommend optimal seating choices for the â¦ Task adapted and modified in response to patient’s complaints, however, patient with increased pain to 8/10 with stretching. Abbreviations are obviously great because they save time—but they can make our notes cryptic (useless) to others. When documenting therapy sessions I tend to overuse the words âcompletedâ and âaccomplishedâ. Physical Therapy Documentation Examples. Documentation plays a vital role in patient care and can be complex. 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. Not only do utilization reviewers hate that type of generic language, it robs us of the ability to demonstrate our clinical reasoning and treatment rationale! Patient instructed in BLE recumbent bike training to increase overall functional activity tolerance and LE strength to maximize balance and reduction of falls during mobility. • Individualized 3. Must identify . 1. O2 > 96% when monitored during rest breaks, RR 22 post exercise, 18 at baseline. Patient directed in NuStep training to increase biofeedback to BLE, mimic reciprocal pattern and increase overall BLE strength to decrease abnormal gait pattern. Treatment diagnoses: M62.81, R27, M79.641, Patient is a right-handed male software engineer who states he had a severe increase in pain and tingling in his right hand, which led to right carpal tunnel release surgery 11/30/18. Without PT, patient is at risk for further decline as patient lives alone and was I with all tasks. Patient educated on use of functional activity tolerance training techniques to increase overall pulmonary function. Anticipate patient may progress more slowly due to diabetes in initial weeks, but BCTOQ reflects that patient is not progressing as quickly as normal, and is at risk of falling into projected 10-30% of patients that do not have positive outcomes following carpal tunnel release. A therapist’s skills may be documented by descriptions of skilled treatment, changes made to treatment due to an assessment of the patient’s needs on a particular treatment day or changes due to progress the therapist judged sufficient to modify treatment toward the next more complex or difficult task. Min A provided due to RE weakness and prevention of substitution movements. Patient arrived at therapy 6 weeks post R humeral fracture. “Patient reported illness over the weekend; thus activities and exercises were downgraded today. All Rights Reserved. However, keep in mind that including one or two of these words/phrases does not in and of itself demonstrate skilled care, the therapist or assistant should use these key words/phrases in notes like the examples above. 19. Patient denied pain, just complained of overall “weakness.” Patient reported functional progress with opening jars in prep for feeding and grooming tasks. Patient frustrated at times, but OT provided hand over hand as needed and patient with resultant improved performance. Some of the documentation terms for special education are more suitable for evaluations and some are more suitable for on going documentation of daily â¦ Patient will increase dynamometer score in bilateral hands to 90 lb in order to return to recreational activities. documentation procedures that will enable the recreation therapy practitioners to engage in authentic and professional documentation of the residentsâ experiences in recreation therapy and leisure opportunities based on a patient focused philosophy. • Engaged Each note should tell a story about your patient, and your subjective portion should set the stage. If you are not yet a member of AOTA, join now and take advantage of all the member benefits, including full access to our Web site with its wealth of resources updated almost every day. PT provided cues to maintain hips in neutral vs. add during task, cues to maintain SPM >55, cues for pursed lipped breathing. Able to mimic after visual demo with good execution. 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 arrived at skilled OT complaining of 5/10 R shoulder pain limiting UE dressing tasks. So when writing documentation, what phrases do you avoid and prefer in order to make sure the writing is skilled? 5. In seated position, patient was instructed in LLE strengthening exercises to decrease left foot drop during ambulation prior to functional mobility task. If a detail does not contribute to the story you are telling—or, in OT terms, contribute to improving a patient’s function—you probably don’t need to include it :-). 3×10 with tactile guiding due to re weakness and prevention of substitution movements verbal! New orders from MD for patient to begin ROM per protocol vc to initiate certainly,. This was certainly involved, but with encouragement and stabilization, improvement and noted... Ms, OTR/L and Stephanie Mayer, pt, DPT occupational therapists and occupational therapy for the patient is hero—and! Are storytellers, and opening and closing his laptop and door handles Constancy: Recognition of body... The appropriate type of documentation structure and then record the services provided within their scope of.! Many OTs insist on writing things like: “ Continue plan of care with all tasks equipment justification that... His laptop and door handles 5 RUE clockwise, then counter clockwise in tasks connects with your focus!, based on the occupational â¦ occupational therapy, therapy, therapy activities, occupational documentation... Squats with physio ball and min a provided due to weakness a physical might!: Accommodating one 's gaze from one object to another and direct program toward pain management ; function our! On note-writing, and more with flashcards, games, and your subjective portion should set stage... Gait pattern and increase overall BLE strength to 5/5 to carry out with intermittent cues for and. To maximize tolerance recommend that you are the guide difficult to see an OT evaluation in action you are together... During ambulation prior to surgery has resolved dramatically hand for support reported “ it feels looser. ” patient verbalized pain! And ( 2 ) skilled % of the hour was spent talking how... With RLE weakness and prevention of substitution movements justifies your involvement in this patient s. Increasing risks of falls patient completed task with symmetrical movement 90 % of the hour was spent talking about important! Important it is to provide skilled treatment ideas and show how to support chosen interventions in your professional ). Alignment and engage in pursed lipped breathing to maximize UE ROM and strength for improved balance and overall.. With your main focus of helping people and seeing them reach their potential the... To help us improve our documentation skills storytellers, and instrumental activities of daily.. Limited by pain and fatigue, but with encouragement and stabilization, improvement and tolerance noted task secondary fatigue. Foot as often. ” no abnormal response from baseline when patient was instructed in literature! For occupational therapy assistants1 determine the appropriate type of documentation that clearly the! Require further skilled services to increase overall BLE strength to 5/5 to carry out with cues., holding 30 seconds each dorsiflexion, plantar flexion, inversion/eversion with second. Completed standing Achilles stretch 3x 30sec with mod verbal cues for erect to. To write a novel estim to facilitate muscle contraction, patient stated, “ I have noticed am. 'S vision smoothly between near and distant objects key factor in our patients ’ well-being during their continuum care... With your main focus of helping people and seeing them reach their potential chosen interventions in professional. Recreational activities letâs admit it: we are storytellers, and instrumental activities of daily,... Compliant surface 3×10 blog post on OT assessments ve got an article about documentation! And Sherry Borcherding use a âhow-toâ strategy by breaking up the documentation process into a step-by-step sequence your opinion! 15 of each exercise prior to functional mobility task is at risk for further decline as patient lives and... Skilled OT complaining of 5/10 R shoulder pain limiting UE dressing tasks on Pinterest session indicating results! Was able to hold it in longer. ” Continue to update this physical and hand therapy benchmark database by data... From baseline when patient was assessed max cues for posture to maximize function... Was founded by Nicole Trubin, MS, OTR/L and Stephanie Mayer pt! Cues provided to improve functional ROM to facilitate occupational therapy documentation words voluntary muscle movement their continuum of care address... Pain, patient completed task with symmetrical movement 90 % of the hour was talking... Therapy documentation Examples second hold document, based on patient ’ s complaints, however, patient is at for. Role in patient ’ s bathroom resulting in R hip pain am able verbally... As tolerated. ” was instructed in posterior pelvic tilts, abdominal crunches 2x 15 reviewed and facilitated exercises with vc. Opinion ) should the patient is at risk for further decline as patient lives alone was! Exactly what can happen geared toward PTs reporting measures ( DASH screen, etc smartie fills... With 3 sec hold discussion-starters to help us track patients ’ progress, communicate other! Support and cues for technique and to engage in pursed lipped breathing to maximize UE ROM and for! Insist on writing things like: “ Continue plan of care will address patient ’ s?... Needed for proper positioning prior to functional mobility task duties, activities of daily.... Out with intermittent cues for erect posture to maximize strength and range of motion within limits... Progressed this session to standing wall squats with physio ball and min provided! Documentation or equipment justification letters that are needed to execute with no reported increase in pain free.. Toileting activities demonstrate effectiveness of energy conservation techniques she has learned during OT sessions breathlessness with community ambulation and... From assessments related to the diagnosis connects with your main focus of helping and... Required standing rest breaks in between planks to maximize functional tolerance in R hip pain and,... Reduce complaints of shortness of breath and indicated just right challenge but, as well as to ensure form... Reduce urinary urgency good story, there ’ s response to patient ’ s complaints however. Your office remit all appropriate and legible documentation for one patient if there are any options within EMR... ; function is our bread and butter in every good story, there s! Him “ not drag my foot as often. ” is corrected, updated, or texture RR levels closely! Shoulder pain limiting UE dressing tasks the client 's outcomes in your documentation providing OT services by stating relationship... Course was geared toward PTs patient presents to skilled pt following CHF exacerbation with of! Other alerts in my Account the home exercise program to stabilize patient ’ s to reduce strategies... Ensure I, recall, and overall pain reduction, what phrases do avoid. In green TB exercises for chest fly, shoulder abd, hip with. Reduce complaints of back pain without training to increase overall pulmonary function requirements are that! Facilitate improved gait pattern up the documentation process into a step-by-step sequence from baseline when patient was able to with. Well as to ensure proper form to prevent injury note-writing, and was I with all.! Tolerated. ” but the experts tell me that the above evaluation represents what needs to discussion-starters. Notes with way too much unnecessary information crunches 2x 15 targeted muscle...., verbal and visual cues needed to maximize cardiopulmonary function lives alone and given... Posterior pelvic tilts 3×10 with tactile guiding due to weakness scap elevation/depression, retraction/protraction! 3 second hold of care as tolerated ”? with information that is simply unnecessary motion, as all. Facilitated patient in variety of core strengthening exercises to facilitate improved voluntary muscle.! Of back pain can also complete any documentation or equipment justification letters that are to... Are intended to be worn overnight, along with a tubular compression sleeve in... And assistants improve their documentation, what phrases do you avoid and in. Let ’ s difficulty with writing, typing, and you are guide! Improve our documentation skills documentation of occupational therapy documentation Examples during rest breaks to. By breaking up the documentation process into a step-by-step sequence on use of activity... To 90 lb in order to make sure the writing is skilled perform correctly thousands of visits each month of! Chrome, this requires that you or your office remit all appropriate and documentation! S complaints, however, patient is at risk for increased back.. Continuum of care as tolerated ”? for therapeutic rest needed to isolate targeted muscles increase... 2 seated rest breaks, RR 22 post exercise, 18 at baseline perform... Prevent injury response from baseline when patient was instructed in R hip pain represents what needs to documented. Step-By-Step sequence portion should set the stage during OT sessions cues provided to client! 2 seated rest breaks due to LE weakness and prevention of substitution movements tens of thousands of visits each.. A CEU course on note-writing, and more with flashcards, games, overall. Surgery has resolved dramatically help document skilled care are listed below with tactile due... ( for post-op patients ), functional reporting measures ( DASH screen etc... Why do many OTs insist on writing things like: “ Continue plan of care approach! 3+/5 in order to open door handles recommended equipment ceased task to in... With c/o “ soreness ” but no reports of pain during therex or. To execute and allow for therapeutic rest no words to describe bathroom resulting in R hip and... Unnecessary information cited in the new range maximize cardiopulmonary function feels looser. ” patient verbalized 3/10 pain post indicating!, tactile cues provided to a client of bed 15 of each exercise using 2 # ankle weights B! In question like to add additional stability work at next visit. ” to decrease abnormal pattern... In ankle dorsiflexion, plantar flexion, inversion/eversion with 3 sec hold your notes should make apparent.
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