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Ohio Occupational Therapy Documentation

What are the occupational therapist’s documentation responsibilities?

The occupational therapist shall assume professional responsibility for the following activities, which shall not be wholly delegated, regardless of the setting in which the services are provided:

    • Interpretation of referrals or prescriptions for occupational therapy services;
    • Interpretation and analysis for evaluation purposes;
    • Development, interpretation, and modification of the treatment/intervention plan and the discharge plan.

What are the assistant’s documentation responsibilities?

An occupational therapy assistant (OTA) may gather and summarize objective information; however they may not interpret the data. It is the occupational therapist's responsibility to interpret the data gathered by the OTA and make the recommendations for discharge plan development.

Document the progress and outcomes summary.

Evaluation

A comprehensive evaluation is essential to determine if OT services are medically necessary, gather baseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation is usually completed in a single session. An evaluation is needed before implementing any OT treatment. Evaluation begins with the administration of appropriate and relevant assessments using standardized assessments and tools. The evaluation must include:

  • Prior functional level, if acquired condition;
  • Specific standardized and non-standardized tests, assessments, and tools;
  • Analytic interpretation and synthesis of all data, including a summary of the baseline findings in written report(s);
  • Objective, measurable, and functional descriptions of an individual’s deficits using comparable and consistent methods;
  • Summary of clinical reasoning and consideration of contextual factors with recommendations;
  • Plan of care with specific treatment techniques or activities to be used in treatment sessions that should be updated as the individual’s condition changes;
  • Frequency and duration of treatment plan;
  • Functional, measurable, and time-framed long-term and short-term goals based on appropriate and relevant evaluation data;
  • Rehabilitation or habilitation prognosis;
  • Discharge plan that is initiated at the start of OT treatment.

Treatment Sessions

An occupational therapy session can vary from fifteen (15) minutes to four (4) hours per day; however, treatment sessions lasting more than one (1) hour per day are rare in outpatient settings. Treatment sessions for more than one (1) hour per day may be medically appropriate for inpatient acute settings, day treatment programs, and select outpatient conditions, but must be supported in the treatment plan and based on an individual’s medical condition. These sessions may include:

    • Evaluation;
    • Therapeutic use of everyday life activities;
    • Treating underlying impairments in preparation for the individual’s engagement in purposeful activity (occupation);
    • Compensation, modification, or adaptation of activity or environment to enhance performance;
    • Management of feeding, eating, and swallowing to enable eating and feeding performance;
    • Basic activities of daily living, self-care, self-management, and home management;
    • Higher level independent living skills instruction and community/work integration;
    • Modification of environments (home, work, school, or community) and adaptation of processes, including the application of ergonomic principles;
    • Assessment, design, fabrication, application, fitting, and training in assistive technology, adaptive devices, and orthotic devices;
    • Training in the use of prosthetic devices;
    • Functional community mobility;
    • Functionally oriented upper extremity exercise programs;
    • Cognitive, perceptual, safety, and judgment evaluations and training;
    • Training of the individual, caregivers, and family/parents in home exercise and activity programs;
    • Skilled reassessment of the individual’s problems, plan, and goals as part of the treatment session;
    • Coordination, communication, and documentation;
    • Reevaluations, if there is a significant change in the individual’s condition.

Documentation of treatment sessions must include:

    • Date of treatment;
    • Specific treatment(s) provided that match the procedure codes billed;
    • Total treatment time;
    • The individual’s response to treatment;
    • Skilled ongoing reassessment of the individual’s progress toward the goals;
    • Any progress toward the goals in objective, measurable terms using consistent and comparable methods;
    • Any problems or changes to the plan of care;
    • Name and credentials of the treating clinician.

Progress Reports

In order to reflect that continued OT services are medically necessary, intermittent progress reports must demonstrate that the individual is making functional progress. Progress reports should include at a minimum:

    • Start of care date;
    • Time period covered by the report;
    • Medical and therapy treatment diagnoses;
    • Statement of the individual’s functional level at the beginning of the progress report period;
    • Statement of the individual’s current status as compared to evaluation baseline data and the prior progress report, including objective measures of the individual’s function that relate to the treatment goals;
    • Changes in prognosis and why;
    • Changes in plan of care and why;
    • Changes in goals and why;
    • Consultations with other professionals or coordination of services, if applicable;
    • Signature and title of licensed professional responsible for the therapy services.

Reevaluation

A reevaluation is usually indicated when there are new significant clinical findings, a rapid change in individual’s status, or failure to respond to occupational therapy interventions. There are several routine reassessments that are not considered reevaluations. These include ongoing reassessments that are part of each skilled treatment session, progress reports, and discharge summaries.

Reevaluation is a more comprehensive assessment that includes all the components of the initial evaluation, such as:

    • Data collection with objective measurements based on appropriate and relevant assessment tests and tools using comparable and consistent methods;
    • Making a judgment as to whether skilled care is still warranted; 
    • Organizing the composite of current problem areas and deciding a priority/focus of treatment; 
    • Identifying the appropriate intervention(s) for new or ongoing goal achievement; 
    • Modification of intervention(s);
    • Revision in plan of care if needed;  
    • Correlation to meaningful change in function;
    • Deciphering effectiveness of intervention(s).

Citation

Ohio Admin. Code ยง 4755-7-02

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