Module Author: Debbie Amini, EdD, OTR/L, FAOTA
Earn .15 CEU (NBCOT 1.88 PDUs/1.5 contact hours)
Effective documentation is essential for occupation-based practice, client care, and reimbursement for occupational therapy (OT) services. This module, the second in AOTA’s Documentation Series, addresses the importance of occupation-based goals in the context of reimbursement requirements and OT best practices. The domain and process of occupational therapy, especially the 8 occupations outlined in the Framework, and Medicare requirements are examined in the first half of the module. The 5 components of a comprehensive documentation system, specifically initial evaluation, plan of care and treatment notes, are addressed in the second half of the module. Examples of long-term and short-term goals are presented along with the COAST method for creating measurable, occupation-based goals. The module concludes with guidelines for creating occupation-based goals that address the needs, wants and desires of the client.
• Mobile Access – this course is easily viewed on a tablet making your learning portable and facilitating on-the-job access to resources.
1. Describe the importance of documentation that captures OT interventions and outcomes.
2. Describe the components of best practice documentation.
3. Identify the components of occupation-based goal statements.
4. Apply the tenets of occupation-based goal writing to your practice setting.