OTH1006 Documentation Through the Occupational Therapy Process
This course will provide an overview and practice of documentation in Occupational Therapy as it is used throughout the therapy process. The primary focus will be on the O.T.A.’s role in documenting intervention plans and progress through the problem oriented medical record (SOAP or other format) notes and school-based (IFSP, IEP) goals and objectives. The course will also provide an overview of documenting screening/evaluation results, goal writing, home or school program development, discharge planning, and outcomes documentation in collaboration with the OT. Other overview topics include ethical responsibility for documentation, legal/regulatory effects on documentation, confidentiality, relevance of medical chart information, electronic documentation, payor- and setting- specific documentation and reimbursement, and administrative and quality improvement documentation.
Offered
Spring