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Wisconsin OT Treatment Program
The occupational therapist is responsible for the development of the occupational therapy intervention plan. The occupational therapist develops the plan collaboratively with the client, and may include the occupational therapy assistant and team working with the client, including the physician — as indicated.
The program shall be stated in measurable and reasonable terms appropriate to the individual’s needs, functional goals and prognosis and shall identify short and long term goals.
The program shall be consistent with current principles and concepts of occupational therapy theory and practice.
In developing the program, the occupational therapist alone or in collaboration with the occupational therapy assistant shall also collaborate, as appropriate, with the individual, family, other health care professionals and community resources; shall select the media, methods, environment, and personnel needed to accomplish the goals; and shall determine the frequency and duration of occupational therapy interventions provided.
The program shall be prepared and documented within the time frames established by the applicable facility, community, regulatory, or funding body.
The occupational therapy program shall be implemented according to the program plan previously developed. The occupational therapist may delegate aspects of intervention to the occupational therapy assistant dependent on the occupational therapy assistant’s demonstrated and documented service competency.
The individual’s occupations, occupational performance, skills, occupational performance patterns, and occupational performance contexts and environments shall be routinely and systematically evaluated and documented.
Program modifications shall be formulated and implemented consistent with the changes in the individual’s occupational performance skills, occupational performance patterns and occupational performance contexts and environments.
All aspects of the occupational therapy program shall be routinely and systematically reviewed for effectiveness and efficacy.
Discontinuation of Services
Occupational therapy services shall be discontinued when the individual has achieved the program goals or has achieved maximum benefit from occupational therapy.
A comparison of the initial and current state of functional abilities and deficits in occupational performance skills, and occupational performance patterns, affecting performance in the individual’s occupations shall be made and documented.
A discharge plan shall be prepared, consistent with the interventions provided, the individual’s goals, and the expected prognosis. Consideration shall be given to the individual’s occupational performance contexts and environments including appropriate community resources for referral, and environmental factors or barriers that may need modification.
Sufficient time shall be allowed for the coordination and effective implementation of the discharge plan.
Recommendations for follow−up or reevaluation shall be documented.
Wis. Admin. Code § OT 4.03
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