OTA 115 - Documenting Occupational Therapy

Credits: 2
Lecture Contact Hours: 2
Description: This course introduces documentation of the Occupational Therapy (OT) process in a variety of styles and formats for the range of populations served, with a focus on electronic health records. Knowledge of the Subjective, Objective, Assessment and Plan (SOAP). Note writing format will be emphasized to allow proficiency in identifying subjective and objective information, as well as assessment and plan of treatment. Students will learn to differentiate between initial, interim and discharge notes and develop the ability to formulate treatment goals. Legal and ethical issues related to documentation and reimbursement will be addressed. Knowledge of the quality assurance process used in OT practice, as well as the insurance claim appeals process, will be provided.

Prerequisites: Admission to the Occupational Therapy Assistant Program. ENG 101 . ENG 106 . HIT 100 or HIT 104 . OTA 110 .
Corequisites: OTA 120 . OTA 130 . OTA 135 .
Recommended: None

Course Category: Occupational
This Course is Typically Offered: Fall
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Course Competencies
1. Analyze the rationale for using problem oriented medical records (POMR) to record patient medical data in rehabilitation and other settings.

2. Differentiate the roles and responsibilities of the Occupational Therapist and the Occupational Therapy Assistant in documentation.

3. Summarize HIPAA regulations with relation to patient confidentiality in medical records.

4. Utilize medical terminology, abbreviations and symbols commonly found in rehabilitation and other settings.

5. Interpret the correlation between objective data, assessment, long term goals and plan of care established by the therapist.

6. Construct a Subjective, Objective, Assessment and Plan (SOAP) note from information given in a case study.

7. Differentiate between an initial evaluation, progress/interim note and discharge summary.

8. Examine the utility of the Functional Independence Measure (FIM) as a uniform system of measurement for disability when documenting rehabilitative services.

9. Appraise the various types of problem-oriented documentation in rehabilitation and other settings.

10. Explain components of a discharge summary and reasons for patient discharge.

11. Summarize the relationship between the medical record and quality assurance, billing, the appeals process and third-party payer guidelines.

12. Outline the legal and ethical implications of documentation, including the therapist/assistant liability.