AOTA

Jessie Franco, OTD, MS, OTR/L  

Senior therapist at Brigham and Women's Hospital,

Boston, MA

Sarah Miller, MSOT, OTR/L 

Lead occupational therapist at Brigham and Women’s Hospital

Boston, MA

Course Credit: Earn .15 AOTA CEU (1.5 contact hours/1.88 NBCOT PDU)

Description: In this comprehensive course, participants will gain the knowledge needed to excel in documentation within the acute care setting. Learners will cover critical background information about the importance of documentation, the history of electronic documentation, and laws and legislation that has impacted it in recent decades. Subsequent lessons delve into crucial topics, such as the importance of documentation in acute care, tips for popular Electronic Medical Record (EMR) systems, goal writing, and strategies for justifying Occupational Therapy (OT) services while effectively tracking patient progress.

Learning Objectives:

• Summarize the overall goal of documentation in the acute hospital setting.
  
• List appropriate methods to improve documentation efficiency.
  
• Apply guides for goal writing to the acute care setting for specific units and patient conditions.
  
• Discuss methods to track patient outcomes to justify services and demonstrate progress.

Domain of OT: Process-evaluation, intervention, discharge, outcomes

Level of Difficulty: Beginner

Audience: Occupational therapists, occupational therapy assistants, occupational therapy and occupational therapy assistant students