Documentation for Occupation-Based Practice Debbie Amini, EdD, OTR/L, CHT, FAOTA Chicago, IL April 8, 2016 Objectives • Describe the importance of documentation that captures OT interventions and outcomes • Describe the components of best practice documentation • Identify the components of occupation based goal statements • Apply the tenets of occupation based goal writing to your practice setting
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Objectives Occupation -Based Practice … for Occupation -Based Practice Debbie Amini, EdD , OTR/L, ... skilled nursing facilities and home ... Unnecessarily limiting.
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Documentation for Occupation-Based Practice
Debbie Amini, EdD, OTR/L, CHT, FAOTA
Chicago, IL
April 8, 2016
Objectives
• Describe the importance of documentation that
captures OT interventions and outcomes
• Describe the components of best practice
documentation
• Identify the components of occupation based goal
statements
• Apply the tenets of occupation based goal writing to
• Purpose: Improve the data collected from clients at long term care hospitals, in-patient rehab facilities, skilled nursing facilities and home health agencies. The goal is to have more consistent and accurate data of patient status and resource use and to understand quality of care. Data must reflect functional outcomes.
Support best practice occupational therapy
• Supports the profession as we work toward occupation based outcomes with the client as the active participant.
• Reinforces the efficacy and importance of OT services.
• Supports and articulates OTs scope of practice to outside agencies and consumers.
• Positively influences trends in reimbursement for services.
• Ensures accurate reporting of what we address and how it is addressed through our lens.
• Ensure alignment of clinical problems, goals and interventions to improve ease of treatment planning, execution and reporting.
Getting Started
• Documentation for occupation based practice
starts with a practice lens that is occupation
based
• Occupational Therapy Practice Framework, 3rd edition
• Overarching Statement:
“Achieving health, well-being and participation in life through engagement in occupation”
Evaluation that includes
• Occupational Profile
• Use outcome measures such as COPM
• Analysis of occupation
• Information obtained in profile informs choice of high quality measures to identify and form a baseline of deficits in skills, patterns, factors or the environment/context that limit participation in the identified area
Areas of Occupation
per Occupational Therapy Practice Framework 3rd edition 2014
• ADL’s: Self Care activities
• IADL’s: Care for others
and Home
• Rest and Sleep:
Preparation for and
rejuvenating rest
• Social Participation: Ability
to interact with others
• Work: Vocational and
Avocational pursuits
• Play: Spontaneous
enjoyable activity
• Leisure: Planned time
away from work and ADL’s
• Education: Planning for
and attending learning
events
Client Factors
Are supports or barriers to participation, but are not problems or goals
• Values, Beliefs and Spirituality
• Body Functions
– Mental functions
– Sensory functions
– Neuromusculoskeletal and movement-related functions
– Cardiovascular, hematological, immunological, and respiratory system functions
– Voice and speech functions, digestive, metabolic and endocrine system, genitourinary and reproductive functions
– Skin and related structure functions
• Body Structures
– Structures of the nervous system
– Structures of the skin
– Structures of the musculoskeletal system
– Etc…
Performance Skills
Are supports or barriers to participation, but are not problems or goals
• Motor skills
– Posture
– Mobility
– Coordination
• Process skills
– Energy
– Knowledge
• Social interaction skills
– Physicality
– Information exchange
Performance Patterns
Are supports or barriers to participation, but are not problems or goals
• Habits
– Acquired tendencies that can support or interfere with performance
• Routines
– Patterns of behavior
• Rituals
– Symbolic actions
• Roles
– Set of behaviors
Context and Environment
Important to consider and include in problems and goals as needed
Contexts Environments
• Cultural: Customs, beliefs and activity patterns
• Personal: Aspects of the client themselves (age, gender, socioeconomic status, etc)
• Temporal: The experience of time as shaped by engagement in occupation. Also, stage of life, time of year, etc.
• Virtual: Communication occurs without physical contact via airways or internet.
• Physical: Natural and built
non-human surroundings
and the objects within them
• Social: Presence of and
relationships with persons,
groups and populations with
whom clients have contact
Targeting Outcomes
• Occupational performance
• Improvement
• Enhancement• Prevention
• Health and Wellness
• Quality of life
• Participation
• Role competence
• Well being
• Occupational justice
Types of Required Documentation
1. Initial Evaluation*
2. Plan of Care *
3. Treatment Note*
4. Progress Report
5. Discharge Summary
Requirements of Initial Evaluation
The evaluation must include:
• Objective statements indicating a decline in occupational performance
• Objective measures
• Statement that SKILLED service is reasonable and necessary
• Indication that qualified personnel are providing services
Decline in Occupational Performance
• Document the diagnosis/diagnoses and specific problems to be evaluated.
• Document the client’s prior level of function. To set the stage for why current function is a decline.
• Document and describe how and why any complicating conditions (ex. ETOH abuse, Mental Illness) may affect treatment.
Decline in Occupational Performance
• Identify physical, cognitive, and psychological impairments that
interfere with independence or safety in occupational performance areas.
• Identify client needs and wants and how these are not currently being realized.
oCanadian Occupational Performance Measure
Requirements of Initial Evaluation
The evaluation must include:
• Objective statements indicating a decline in occupational performance
• Objective measures
• Statement that SKILLED service is reasonable and necessary
• Indication that qualified personnel are providing services
Objective Measures
Objective measurements gathered from valid and reliable tools should describe the client’s functional performance in areas of occupation
• Used to Identify baseline function that will be used to determine change in future performance outcomes.
• Used to describe the specific problem being evaluated and identify the body part being treated.
• Used as links to explicitly connect client’s function to reproducible criteria
Valid and Reliable
• Must consider strength of tools used
• Valid tools measure what they say they will measure.
• Reliable tools provide reproducible results.
• Many tools in the world of OT are “home grown”. They have been used for years without benefit of supportive research.
• Be a good consumer of available resources and consider standardized assessments
Examples of Valid and Reliable assessment tools
• Executive Function Performance Test
• Bruininks-Oseretsky Test of Motor Proficiency, 2nd Ed.(BOT™-2)
• Texas Functional Living Scale (TFLS)
• Montreal Cognitive Assessment (MoCA)
• AMPS (Assessment of Motor and Processing Skills)
• Client interview (typical OT approach to information gathering—interest checklist etc.)
Requirements of Initial Evaluation
The evaluation must include:
– Objective statements indicating a decline in occupational performance
– Objective measures
– Statement that SKILLED service is reasonable and necessary
– Indication that qualified personnel are providing services
Skilled Service is Reasonable and Necessary
• Document that significant and realistic improvement is expected in a reasonable period of time OR that skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration (maintenance therapy).
• The amount, frequency, and duration of service must fit within accepted standards.
Skilled Service is Reasonable and Necessary
• Intervention must be specific and effective for the client’s condition (evidence based) – Sidebar: What is evidence based practice?
• The need for services that require the qualifications of an OT/OTA must be made explicit. The condition and treatment must be of the complexity and sophistication that warrant skilled service.
• The skills of an OT/OTA are necessary to meet the client’s need.
» Maintenance therapy – specific requirements Jimmo v. Sebelius
Skilled Service is Reasonable and Necessary
Are part of the initial evaluation and subsequent treatment
notes
• Example of a Skilled Therapy Statement:
“Skilled therapy is necessary to provide appropriately
designed cognitive activities to improve problem solving and
sequencing needed for independent meal preparation.”
Requirements of Initial Evaluation
The evaluation must include:
– Objective statements indicating a decline in occupational performance
– Objective measures
– Statement that SKILLED service is reasonable and necessary
– Indication that qualified personnel are providing services
Qualified Personnel
Per AOTA, Various State and Other Payer Regulations• An OT or an OTA is providing the skilled service (check 3rd payer requirements)
• An OT initiates and directs the screening, evaluation, and re-evaluation process and analyzes and interprets the data.
• OTAs may provide objective data.
• OTAs act under the supervision of the treating therapist.
• The therapist must actively participate in the evaluation/re-evaluation
Types of Required Documentation
1. Initial Evaluation*
2. Plan of Care*
3. Treatment Note*
4. Progress Report
5. Discharge Summary
Plan of Care
• Problem List
• Long Term Goals
• Short Term Goals (not required for, but mentioned in
Medicare guidelines).
• Skilled services to be provided (including time frame and
intervention techniques)
Problems
• Must reflect area that client wishes to address
• Based on outcomes of assessments
• Must be relevant to diagnosis/reason for referral
• Should be areas that OT will address
• Do not list medical diagnosis as problem (list as
limitation or describe in text of report)
• Based on OCCUPATIONS not client factors, skills,
patterns or contexts
• Will set the stage to occupation based interventions
and outcome
Caution: Including Factors in Problem Statement
• Not necessary to add the reason for the functional problem in the problem statement. This information should be included in the outcome statements within the text of the evaluation.
• Unnecessarily limiting. Confuses the focus of intervention.
EX. Client is unable to don LE clothing due to limited shoulder ROM.
This statement creates the impression that no other issues exist. What if shoulder movement becomes normalized and client continues to be unable to don pants? Will require re-working problems and goals.
Examples of Factor vs. Occupation-based problems
Factor-based
• Client has low self-esteem.
• Child obtained 50th
percentile on the BOT2.
• Client cannot flex left
shoulder beyond 90
degrees.
• Client has poor endurance.
• Client cannot close hand to
grasp.
Occupation-based
• Client unable to engage in
social pursuits.
• Child is unable to participate
in arts and crafts class with
peers.
• Client is unable to engage in
leisure activity of yard care.
• Client unable to prepare meal
for family.
• Client cannot feed self
Plan of Care
• Problem List
• Long Term Goals
• Short Term Goals (not required for, but
mentioned in Medicare guidelines)
• Skilled services to be provided (including
time frame and intervention techniques)
What are goals?
• Statements that describe the state of being that is being
worked toward in treatment. Reaching that state of
being should indicate that the initially identified
functional problem has been appropriately resolved.
Where do occupation-based goals come from?
• A client centered evaluation
• A client centered and evidence based plan of care
• Appropriate documentation of relationship between
assessment tool outcomes and occupational deficits
• Occupation based problem statements
2 Types of Goal Statements
•Long term goals• Can be known as treatment goals
• Are the goals recognized primarily by most 3rd party carriers
• When complete, should indicate that the occupational problem has been resolved or reduced
• Must be measurable, occupation-based, timed and client focused
• Specifically address problems
Long Term Goals
• Client unable to engage in social pursuits.
• Client will consistently engage in desired social interactions with family members by 10-15-15.
• Client is unable to dress self independently
• Client will independently dress self using adaptive equipment by 10-12 -15.
Short Term Goals
• Are sub components of LTG’s
• When completed, should indicate that LTG has been reached.
• Should be occupation based, measurable, timed, client focused and relate specifically to the LTG.
• Should be a minimum of 2 for each LTG
Short Term Goals
Client unable to engage in social pursuits.
Client will consistently engage in desired social interactions with family by 10-15-16.
• Client will contact mother one time to secure details about upcoming family event by 9-15-16.
• Client will arrange and take transportation to 2 hour family event by 9-23-16.
• Client will have 4 positive conversations (10 minutes each) with a minimum of three family members during family event by 10-7-16.
Short Term Goals
• Child is unable to participate in arts and crafts class with
peers.
• Child will fully participate in second grade arts and crafts class with peer group at close of school year
• Child will create a three inch clay pot using assigned pinch method by April 1, 2016.
• Child will demonstrate the ability to create a holiday card using three shapes accurately cut out of construction paper using scissors by April 15, 2016.
• Child will demonstrate the ability to create a construction paper zoo scene including the gluing of previously cut out animal shapes by May 1, 2016.
Optional 3rd level Behavioral Objective
• May help therapists who really really need to make the
connection to body functions and structures explicit.
• Use as daily or weekly sub units of short-term goals.
• Not looked at by third party payers, but can serve as
guides for therapists who need to see relationship
between factors and occupations.
Examples of Behavioral Objectives
• Client is unable to dress self independently• Client will independently dress self using AE by 10/12/16
• Client will don pants using a dressing stick by 10/5/16
• Client will demonstrate full grasp of right hand to securely hold dressing stick.
• Client will independently doff pants by 10/1/16
• Client will increase should flexion to 135 degrees to allow reaching to feet for pant removal.
Telescoping of Problems, LTG’s and STG’s
Test of occupation-based goals and problems
If goal relates to more than one or two areas of occupation it
is likely NOT occupation based.
Goal will be a component of an occupation. It is a client factor
or skill that is needed for completion of many occupations.
“Client will actively flex shoulder to 160 degrees 3 out
of 4 attempts by 10/1/16.”
Writing Goals in Measurable Occupation-based format
• Several sources offer acronyms for what to include in goals.
• Regardless of acronym, good goals contain the following basic parts:
– Indication of WHO is completing the goal
– Indication of WHAT is being completed
– Indication of HOW is it to be completed
– Indication of WHEN is it to be completed
– Indication of WHERE the behavior is to be completed (if needed)
COAST Method
C: Client will perform
O: What Occupation
A: With what level or assistance or
independence
S: Under what specific condition
T: Time frame
Client
– Goals should be written with the client as the center of the outcome.
– Caregiver goals which are sometimes written, can still be client centered.• Try: Client will demonstrate receptivity to having splint
donned by spouse after instruction.• Versus. Spouse will be instructed to apply splint to client’s
hand.– Write from the client’s perspective, not the therapists’.
The client will demonstrate independent teeth brushing using adapted toothbrush 100% of attempts by December 1, 2016.
Occupation
– Indicate the performance that must be completed before the goal is considered met.
– Based on ‘Occupations’ as described in the Framework.
The client will demonstrate independent teeth brushing using adapted toothbrush 100% of attempts by December 1, 2016.
Assistance
• How much assistance will be required when goal is complete
(min assist, moderate assist, verbal cueing).
• Can be phrased in terms of ability of client (independently,
without assistance).
• May be implied.
• Add specialized equipment or context if it supports
performance.
The client will demonstrate teeth brushing using
100% of attempts by December 1, 2016.
• Specify when, where, and with whom the performance should occur or under what circumstances.
• Criteria by which goal completion will be measured.
• May be written as a percentage of all attempts.
• May be written as a number of successes out of number of trials (3 out of 4 attempts)
• May be written as “consistently” or “all attempts”
• May not be written. Consistent ability may be implicit in goal statement. “Client will feed self independently using overhead suspension sling to support dominant arm within 2 weeks.”
The client will demonstrate independent teeth brushing using adapted toothbrush 100% of attempts by December 1, 2016.
Time frame
• Identify the date by which the goal should be met.
• Long term goals should not exceed expected time of
treatment.
• Short term goals cannot exceed time frame for long
term goals and should be attainable within weeks, not
months.
The client will independently brush teeth using adapted toothbrush
100% of attempts by December 1, 2016.
Diagramming Goal Statements
• The client will prepare a light meal 100% of attempts in the OT kitchen with standby guarding of OT practitioner by 11-25-16.
• The child will demonstrate the ability to complete in-class English assignments during time provided by classroom teacher using laptop computer to write answers to prompts 90% of attempts by May 1, 2015.
• Treatment interventions that are occupation or activity
based can easily be created when STG’s reflect the
problems and the LTG’s.
• Interventions can be designed to work on the
occupation itself or on factors, skills or patterns that
specifically address occupational performance.
• Choose interventions based on evidence, frame of
reference, and the type (according to the Framework)
that fit the situation best.
Occupation based practice and goals does not mean…
• That factors, skills and patterns are not
independently addressed.
• That interventions such as preparatory methods
and tasks cannot be used.
IN FACT
• Factors can be addressed outside of an activity
• Non related activities and occupations can be
used to address underlying factors and skills.
Types of Required Documentation
1. Initial Evaluation*
2. Plan of Care*
3. Treatment Note*
4. Progress Report
5. Discharge Summary
Treatment Note
Documentation is required to create a record of all skilled treatment/intervention and time spent in providing the services to justify services billed.
Include
Date of treatment
Name of specific treatment/intervention
As required by the payer, use correct CPT coding language (NEW CPT coming soon)
Name/credentials of who delivered the service
Medicare Part B—Time spent in treatment/intervention represented by timed codes and total treatment time in minutes.
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Treatment Note
• Daily documentation may include:
• Patient self-report
• Adverse reaction to treatment
• Communication with other providers
• Significant, unexpected changes in
clinical status
• Equipment provided
Payers or state practice acts may require different
documentation in treatment notes.
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Sample Treatment Note
September 8, 2015
Client participated in treatment session consisting of 45 minutes of therapeutic activities using one-handed dressing techniques for donning and doffing pants and socks and using a button aid to fasten the buttons of his shirt. Client engaged in 15 minutes of purposeful therapeutic reaching activity prior to dressing to enhance active shoulder motion in preparation for dressing. Skilled intervention of OT practitioner continues to be required for design and administration of appropriate therapeutic activities to continue skill development.
O.B. Therapist, OTR/L
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Date
Specific
interventions to
justify billing code
Signature and
professional title
Time spent in intervention
Include Skilled Therapy Statements
Examples:
• Client was able to demonstrate safe use of stove after skilled service instruction in compensatory techniques for reaching from wheelchair.
• Client was able to successfully don and doff shirt with minimal assist after completion of skilled service program of graded upper-extremity strengthening activities and occupations.
• Client demonstrated less pain and fatigue during the meal preparation activity after skilled service instruction of joint protection techniques and presentation of adapted equipment such as a jar opener and non-skid mat.
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SOAP Note format
September 8, 2015
S: “I am having a pretty good day”
O:Client participated in treatment session consisting of 45 minutes of occupation focused activity using one-handed dressing techniques while donning and doffing pants and
socks, and using a button aid to fasten the buttons of his shirt. Client engaged in 15 minutes of therapeutic reaching activity prior to dressing to enhance active shoulder
motion in preparation for dressing. Skills required for dressing have improved, client now requires only moderate physical assistance to complete dressing tasks. Skilled
intervention of OT practitioner continues to be required for design and administration of appropriate therapeutic activities to continue skill development.
A:Improvements in ADL performance and shoulder mobility continue. Client continues to benefit from OT services including ADL retraining and functional activities to address
UE weakness and limited AROM.
P: Continue with current plan of care 2x/week for 60 minute sessions.
Person-centered Electronic Record For
Outcomes Reporting and MeasurementEMR developed in partnership between
Cedaron and the American Occupational
Therapy Association
Summary
• Occupation based practice and documentation are not just a nice idea, they are necessary
• Use of tools that provide insight into the needs, wants and desires of the client will actually make goal writing, intervention planning and documentation much easier
• Base problems on client reported participation deficits that are classified as OCCUPATIONS in the Framework
• Use the test of occupation-based problems
• Create LTG’s that specifically address the problem (when LTG is
reached, problem is resolved)
• Create STG’s that are components of LTG’s. Upgrade STG’s as
needed until LTG’s are reached
References
American Occupational Therapy Association. (2014). Occupational therapy practice
framework: Domain and process, (3rd ed.). American Journal of Occupational Therapy,
68(Suppl. 1), S1-S48.
American Occupational Therapy Association. (2013). Guidelines for documentation of
occupational therapy. American Journal of Occupational Therapy, 67(6 Suppl.)S 32-S 39.
Brennan, C. (2007). Documentation: The key to successful justification of occupational
Eschenfelder, V. G. (2005). Shaping the goal setting process in OT: The role of meaningful occupation. Physical & Occupational Therapy in Geriatrics, 23(4), 67-81.
Quinn, L., & Gordon, J. (2010). Documentation for Rehabilitation: A Guide to Clinical Decision Making, (2nd ed.). Saunders.