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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:
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.
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:
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:
Documentation of treatment sessions must include:
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:
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:
Ohio Admin. Code § 4755-7-02