Module Author: Karen M. Sames, OTD, OTR/L, FAOTA
Earn .15 CEU (NBCOT 1.88 PDUs/1.5 contact hours)
Effective documentation is essential for client care, reimbursement for occupational therapy (OT) services, and evidence in legal cases of malpractice or neglect. This module, the first in AOTA’s Documentation Series, addresses the what, why, when, where, and who questions pertaining to OT documentation. The first half of the module examines best practices for documentation including writing guidelines and point-of care (PoC) documentation skills. The roles of OTs/OTAs in documentation are delineated, and the advantages and disadvantages of electronic health records are examined. The second half of the module focuses on the documentation requirements for each step in the OT process and provides formats and examples of various types of OT documentation.
· Mobile Access – this course is easily viewed on a tablet making your learning portable and facilitating on-the-job access to resources.
After completing this module, you will be able to:
- Articulate the purposes of occupational therapy documentation.
- Identify when and where occupational therapy documentation occurs.
- Specify who reads occupational therapy documentation.
- Describe OT/OTA role delineation in occupational therapy documentation.
- List advantages and disadvantages of electronic health records.
- Specify best practices in occupational therapy documentation.
- Differentiate the key components of evaluation reports, plans of care, contact notes, progress notes, and discharge summaries.