Documentation of Occupational Therapy Services

Jerilyn (GiGi) Smith

Chapter Outline

Purposes of Documentation

Documentation is a permanent record of what occurred with the client. It is also a legal document and as such must follow the guidelines that will enable it to withstand a legal investigation. Reimbursement depends upon accurate, well-written documentation that provides the necessary information to justify the need for occupational therapy services.

AOTA has identified that the purposes of documentation are as follows:

Clear, concise, accurate, and objective information is essential to communicate the occupational therapy process to others. The clinical record should provide sufficient facts to support the need for occupational therapy intervention.¹³

Documentation is required whenever occupational therapy services are performed. This includes a record of what occurred during direct client care, as well as supportive documentation required to justify the need for occupational therapy intervention.

Best Practices

Regardless of where documentation takes place, several basic technical points are important to adhere to when writing in a medical record. Box 8-1 lists the fundamental elements of documentation as set forth by the AOTA.² Proper grammar, correct spelling and syntax, and well-written sentences are essential components in any professional correspondence. Keeping lists of commonly used terms and using a hand-held spell-check device are two strategies that may assist with spelling difficulties. Poor grammar or inaccurate spelling can lead the reader to question the skills of the therapist. Legibility is important to ensure that misinterpretation does not occur. Only approved abbreviations are to be used in the medical record. All clinical sites should have a printed list of acceptable abbreviations that can be used at the site. It is important to obtain this list and use it as a reference when documenting. Examples of abbreviations commonly used in clinical practice are listed in Box 8-2. Misinterpretation of intended meaning can occur when unfamiliar abbreviations or casual language unsuitable for therapeutic context is used. Language particular to a profession (slang or jargon) should never be used in the client record.

All entries made into the medical record must be signed with the therapist’s legal name. Your professional initials (OTR/L, OTL) should follow your signature. Do not leave blank spaces at the end of an intervention note. Instead, draw a single line that extends from the last word to the signature. This prevents additional information from being added after the entry has been completed.

It is best practice to complete documentation as soon after the therapy session as possible. The longer the time interval between the evaluation or intervention and completion of the written record of the event, the greater the chance that details or other important information will be forgotten. Although documenting at the time of service delivery is ideal, it is not always possible. At these times, it may be beneficial for the therapist to carry a notepad or clipboard to record data that can later be included in the official write-up.

Altering, substituting, or deleting information from the client record should never take place.⁹ Changes made to the original documentation could be used to support allegations of tampering with the medical record, even when this was not the intent of the writer. However, at times, corrections must be made. Several principles should be followed to avoid questioning of the validity of the information. Never use correction fluid when correcting an entry in the client’s record. An acceptable method of correcting an error in the documentation is to draw a single line through the word or words, initial and date the entry, and indicate that this was an “error.” Do not try to obliterate the sentence or word, as this may appear to be an attempt to prevent others from knowing what was originally written. Late entries to the medical record cannot be backdated. If it is necessary to enter information that is out of sequence (e.g., a note that the therapist forgot to write), it must be entered into the medical record as a “late entry” and must be identified as such.⁹ Words or sentences cannot be squeezed into existing text “after the fact.” Attempts to do this may be interpreted as adding missing information to support something that occurred after the original documentation was completed.

Do not leave blank spaces on evaluation and preprinted forms. If it is not appropriate to complete a section, “N/A” can be inserted to indicate that the particular area was not addressed. If sections are left blank, others reading the chart may think these areas were overlooked.

Documentation should incorporate the terminology outlined in the Occupational Therapy Practice Framework-2 (OTPF-2). One of the purposes of the OTPF-2 is to assist therapists in communicating to other professionals, consumers of services, and third party payers the unique focus of occupational therapy on occupation and daily life activities. Documentation should reflect the emphasis of occupational therapy on supporting function and performance in daily life activities and those factors that influence performance (performance skills, performance patterns, activity demands, client factors, context and environment) during the evaluation and intervention process.⁴ Many practice settings that follow the medical model, such as hospitals, use the term patient to describe the recipient of services. Other settings may prefer the term resident. Although these are acceptable, the OTPF-2 advocates use of the term client. Client encompasses not only the individual receiving therapy, but also others who are involved in the person’s life, such as spouse, parent, child, caregiver, employer, and larger groups such as organizations or communities. The OTPF-2 provides terminology that can be used at each stage of the therapy process. This will be explained in further detail when the various parts of the therapy evaluation, intervention, and discharge processes are described.

Clinical Reasoning Skills

Occupational therapists must use clinical or professional reasoning throughout the occupational therapy process. For the purposes of this chapter, the more contemporary term professional reasoning will be used instead of clinical reasoning when referring to the comprehensive types of thinking and judgment used by occupational therapists in making client-related decisions. Professional reasoning also includes determining how to appropriately document information obtained during the evaluation, intervention, and discharge process. Professional reasoning is used to plan, direct, perform, and reflect upon client care.¹⁹ Documentation must demonstrate that professional reasoning was used in the decision-making process during all aspects of the client’s therapy program.

Professional reasoning (also referred to as clinical reasoning by some authors) comprises many different aspects of reasoning: scientific, diagnostic, procedural, narrative, pragmatic, ethical, interactive, and conditional.¹⁹ Scientific reasoning is used to help the therapist understand the client’s impairments, disabilities, and performance contexts and to determine how these might influence occupational performance. Diagnostic reasoning is specifically concerned with clinical problem identification related to the client diagnosis. Procedural reasoning is used when the therapist thinks about the disability or disease and decides upon intervention to remediate identified problems. Narrative reasoning guides the therapist in evaluating the meaning that occupational performance limitations might have for the client. Pragmatic reasoning is used when addressing the practical realities associated with delivery of therapy services while looking at the context or contexts within which the client must perform his/her desired occupations. The therapist’s personal situation such as clinical competencies, preferences for particular therapy techniques, commitment to the profession, and comfort level in working with certain clients/diagnoses is a part of the pragmatic reasoning process. Ethical reasoning is the process by which the therapist determines the most appropriate therapy intervention to address the client’s occupational performance needs.¹⁹ The therapist’s values and general worldview play an important role in ethical reasoning.¹¹ Keeping these points in mind and using professional reasoning skills when determining what and how to document will facilitate client care and reimbursement for therapy services.

Legal Liability

The medical record is a legal document. All written and computerized therapy documentation must be able to endure a legal review. The medical record may be the most important document in a malpractice suit because it outlines the type and amount of care or services that were given.⁹ The therapist must know what information is necessary to include in the client record to reduce the risk of malpractice in a legal proceeding. All information must be accurate and based on first-hand knowledge of care. Deductions and assumptions are to be avoided; judgmental statements do not belong in the therapy notes. The therapist instead should describe the action, behavior, or signs and symptoms that are observed. As described earlier, it is considered fraudulent to alter the medical record in any way.

Initial Evaluation

The initial evaluation is a very important document in the occupational therapy process. It is the foundation upon which all other components of the client’s program (including long- and short-term goals, the intervention plan, progress notes, and therapy recommendations) are based. Evaluation is the process of obtaining and interpreting data necessary for understanding the individual, system, or situation. It includes planning for and documenting the evaluation process, results, and recommendations, including the need for intervention.⁵ The Occupational Therapy Practice Framework-2⁴ stresses that the evaluation process should focus on identifying what the client wants and needs to do, as well as on identifying those factors that act as supports for or barriers to performance. The client’s involvement in this process is essential in guiding the therapist in choosing appropriate tools to assess these areas. The occupational therapist takes into account the performance skills, performance patterns, context, activity demands, and client factors that are required for the client to successfully engage in occupation. This information must be articulated in the initial evaluation write-up.

A clear, accurately written accounting of the client’s current status, as well as a description of his/her prior status, is essential to justify the need for occupational therapy services. This initial report also provides necessary information to establish a baseline against which re-evaluation data and progress notes can be compared to demonstrate the efficacy of therapy intervention. The evaluation must clearly “paint a clinical picture” of the client’s current functional status, strengths, impairments, and need for occupational therapy.

The evaluation should include an occupational profile of the client. The occupational profile includes information about the client’s occupational history and experiences, patterns of daily living, interests, values, and needs.⁴ Information obtained from the occupational profile is essential in guiding the therapist to make clinically sound decisions about appropriate assessments, interventions, and goals.

Assessments are the tools, instruments, and interactions used during the evaluation process.⁵ These include standardized and nonstandardized tests. They can be written tests or performance checklists. Interviews and skilled observations are examples of assessments frequently used in the evaluation process. The specific assessments used are determined by the needs of the client and the practice setting in which the client is being seen. Assessments should be chosen that will evaluate the client’s occupational needs, problems, and concerns. Clinical judgment skills are used to decide which assessments are appropriate and which areas should be evaluated. It is not necessary to evaluate every area of occupation and all performance skills for every individual. For example, it is not appropriate to assess a client’s ability to cook a meal if he/she lives in a setting where meals are provided. Results of the assessment should be clearly identifiable and stated in measurable terminology that is standardized to the practice setting. Table 8-1 shows an example of terminology that can be used to describe the level of assistance required during the performance of a functional task.

AOTA has outlined the recommended components of professional documentation used in occupational therapy in Guidelines for Documentation of Occupational Therapy.¹ Suggestions for what information should be included in evaluation and re-evaluation reports, intervention plans, progress reports, transition plans, and discharge reports are provided.

The evaluation report should contain the following information:

Intervention Plan

Upon completion of the assessment, the intervention plan is established. Information obtained from the occupational profile and the various assessments is analyzed, and a problem list is generated. Problem statements should include a description of the underlying factor (performance skill, performance pattern, client factor, contextual or environmental limitation, activity demand) and its impact on the related area of occupation.⁷ Based on the client’s specific problems, the intervention plan is developed. The therapist must use theoretical knowledge and professional reasoning skills to develop long- and short-term goals, to decide upon intervention approaches, and to determine the interventions to be used to achieve stated goals. Recommendations and referrals to other professionals or agencies are also included in the plan.¹ The intervention plan is formulated on the basis of selected theories, frames of reference, practice models, and evidence.⁴ It is directed by the client’s goals, values, beliefs, and occupational needs.

Establishment of the intervention plan is a collaborative effort between the therapist and the client or, if the client is unable, the client’s family or caregivers. The plan is based on the client’s goals and priorities.^3,4 Although the primary responsibility for development of the intervention plan and goal setting is the role of the occupational therapist, the occupational therapy assistant may contribute to the process.⁵ Goals must be measurable and directly related to the client’s ability to engage in desired occupations. The overarching goal of occupational therapy intervention is “engagement in occupation to support participation.”⁴ This must be kept in mind at all times when developing long- and short-term goals. The Occupational Therapy Practice Framework-2 further identifies the outcome of occupational therapy intervention to be the method that assists the client to reach a state of physical, mental, and social well-being; to identify and attain aspirations; to satisfy needs; and to change or cope with the environment.⁴ Documentation that uses this terminology will support the unique focus that occupational therapy contributes to the client care plan and the rehabilitation process.

The client intervention plan contains both short- and long-term goals. Some therapists prefer to use the term objective in place of short-term goal. Short-term goals or objectives are written for specific time periods (e.g., 1 or 2 weeks) within the overall course of the client’s therapy program. They are periodically updated as the client progresses or in accordance with the guidelines of the practice setting or payer requirements. Short-term goals are the steps that lead to accomplishment of the long-term goal, which is also called the discharge goal in some settings. The long-term goal is generally considered to be the overall functional goal of the intervention plan and is broader in nature than the short-term goal. For example, the client’s long-term goal may be to become independent with dressing. One short-term goal to accomplish this might be that the client will be able to independently don and doff a simple pull-over shirt without fasteners. When this short-term goal is achieved, a subsequent goal might be for the client to be able to dress independently in a shirt with buttons. Eventually, lower extremity dressing would be added as an objective, then socks, shoes, and outerwear, until the long-term goal of independent dressing is achieved.

Establishing functional, client-centered goals that focus on engagement in occupations and activities to support participation in life is central to the philosophy of occupational therapy.⁴ Skillful goal writing requires practice and careful consideration of the desired outcome of therapy intervention. Client-centered goals are written to reflect what the client will accomplish or do, not what the therapist will do, and are written in collaboration with the client. An important characteristic of a goal is that it must reflect an outcome, not the process used to achieve the outcome.¹⁶ “The client will be taught energy conservation techniques to use during dressing” is an example of a poorly written goal that focuses on the process, rather than the outcome of therapy. The correct way to write the goal would be “The client will independently use three energy conservation techniques during dressing.” Goals must be objective and measurable and must include a time frame, which may be discussed in a separate section of the evaluation form. The expected behavior is clearly stated, using concrete terms that describe a specific functional task, action, behavior, or activity (the client will don pants); also, a measurable expectation of performance is identified (independently), with conditions or circumstances that support the outcome listed (using a dressing stick). Well-written goals contain all of the components listed here and avoid the use of vague or ambiguous terms that may be misunderstood by the reader (Table 8-2).

Once goals are established, the therapist, in collaboration with the client, chooses appropriate interventions that will lead to goal attainment. The plan consists of skilled interventions that the therapist will provide throughout the client’s therapy program. Interventions are chosen that involve the therapeutic use of self; the therapeutic use of occupations or activities (occupation-based activity, purposeful activity, preparatory methods); and consultation and client/caregiver education and advocacy.⁴ Examples of occupational therapy interventions include activities of daily living (ADL) training; instrumental activities of daily living (IADL) training; therapeutic activities; therapeutic exercises; splint/orthotic fabrication, modification, and application; neuromuscular retraining; cognitive-perceptual training; and discharge planning. The OTPF-2 outlines various approaches that may guide the intervention process (Table 8-3). These approaches are based on theory and evidence. It is expected that the intervention plan will be modified according to client needs and priorities and responses to the interventions. Modifications to the intervention plan must be documented in the client record in the weekly or monthly progress report.

Progress Reports

Progress toward goal attainment is an expected criterion for reimbursement of occupational therapy services. Documentation that demonstrates progression toward goal achievement is critical to support the need for ongoing therapy. The purposes of the progress report are to document the client’s improvement, to describe the skilled interventions provided, and to update goals. Progress reports can be written daily or weekly depending on the requirements of the work site and the payer source. Various reporting formats are used to document client progress. The most prevalent formats used in physical disabilities settings include SOAP notes, checklist notes, and narrative notes.

Regardless of the format used, progress reports should identify the following key elements of the intervention session: the client outcome (using measurable terminology from the OTPF-2); the skilled interventions provided by the occupational therapist; and progress that resulted from the occupational therapy intervention. Skilled interventions are those that require the expertise, knowledge, clinical judgment, decision making, and abilities of an occupational therapist.¹⁴ Skilled therapy services have a level of inherent complexity such that they can only be performed safely and/or effectively by or under the general supervision of a qualified therapist. Skilled services include evaluation; determination of effective goals and services in collaboration with the client and the client’s caregivers and other medical professionals; analysis and modification of functional activities and tasks; determination that the modified task obtains optimum performance through tests and measurements; client/caregiver training; and periodic re-evaluation of the client’s status with corresponding readjustment of the occupational therapy program. The therapist’s skills may be required for safety reasons, or they may be required to establish and teach the client a compensatory strategy to improve independence and safety. Box 8-4 shows examples of terminology that can be used to demonstrate provision of skilled services.

Documentation of skilled services includes a description of the type and complexity of the skilled intervention and must reflect the therapeutic rationale underlying the task. Reimbursement for clinical services provided is dependent on documentation that demonstrates the clinical reasoning that underlies the intervention. The progress note must reflect progress made toward established goals. Comparison statements are an excellent way to convey this information. Current status information is compared with baseline evaluation findings to clearly identify progress: Client now requires minimal assistance to regain sitting posture during lower body dressing (last week required moderate assistance). Documentation that includes functional assessment scores from validated tests and measurements to demonstrate client progress provides strong justification for reimbursement of therapy services. A statement explaining why additional therapy services are needed substantiates the need for ongoing therapy: Occupational therapy services are required for facilitation of balance and postural corrections during lower body dressing training. Goals are modified and updated on the basis of client progress: Client will don pants independently, without loss of balance, while seated at the edge of the bed. Upgrading of the client’s goals can consist of reducing the amount of assistance required to complete the task, increasing the complexity of the task, or introducing a new component to the activity. This is an ongoing process, and meticulous documentation is necessary to demonstrate the need for continued occupational therapy services.

Types of Documentation Reporting Formats

Documentation can be paper based (written record) or computer generated. The written medical record is still the most widely used method for recording information; however, the electronic medical record (EMR) is becoming more common, especially in large hospital settings. Computerized documentation can be used to record all aspects of the occupational therapy process from the evaluation report to the discharge report. Reporting forms can be inputted into the computer, and results of initial evaluation and the discharge report can be typed directly onto the forms. This guarantees legibility and ensures that no areas are left uncompleted. Increased numbers of regulations, more complex reimbursement structures, and pressure to achieve increased productivity are placing pressure on our current systems; therefore, use of an electronic documentation program may improve therapists’ efficiency.¹⁰

Computerized evaluation forms and progress notes are formatted to meet the needs of the facility and include information required for reimbursement (Figure 8-3). Therapists often are able to choose responses from a pull-down menu, thereby reducing time spent in deciding upon the appropriate terminology to use (Table 8-5). Space is usually available to include narrative information as well. Because all health care providers enter information on a common database, members of the team are able to quickly access information about the patient by reviewing relevant sections on the computerized medical chart. One of the problems or inconveniences that may occur with computerized documentation involves the accessibility of computers. Therapists must allow time to locate a computer that is not in use, so that they can enter their data. Because notes must be entered in chronological order, this sometimes becomes an issue if a computer is not available, as the therapist may not be able to wait until the next day to enter information. Some forms that are on the computer are very restrictive in terms of what information the therapist may enter. This may make it difficult for the therapist to adequately document the session. Often a long time lapse occurs between updates of computer programs. In general, however, computerized documentation and billing can be an asset in the therapy setting. It can enhance therapist productivity by reducing the amount of time spent writing and can guide the new therapist in choosing appropriate responses and terminology to document what occurred with the client.

Many different written formats can be used to document occupational therapy services. The content of the form used is usually determined by the requirements of the third party payer reimbursing the service and the unique needs of the practice setting. As stated before, documentation must contain the information necessary to justify the need for occupational therapy services, must demonstrate the provision of skilled therapeutic interventions, and must show client progress toward identified goals. Occupational therapy documentation should address all of these components to ensure reimbursement and to convey accurate information about client performance.

The primary reimbursement systems for occupational therapy services in the physical disabilities setting include Medicare, Medicaid, and various Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Each of these organizations requires specific information that must be included in the documentation for reimbursement to occur. Individual facilities (e.g., hospitals, clinics, home health agencies, skilled nursing facilities) design documentation forms to meet their specific needs and to ensure that the information necessary for reimbursement is included. Billing systems may also influence the type of documentation format that is used in a particular setting.

Medicare is a major payer source in the geriatric physical disability setting. Medicare is a national insurance program and as such has set national standards for documentation. This government agency has put forth detailed guidelines stating expectations for what information must be included in the medical record to justify the need for occupational therapy services. Intermediaries will reimburse occupational therapy services only if all of the requirements established by the Medicare guidelines and regulations have been met. The Medicare Benefit Policy Manual (www.cms.gov/manuals/Downloads/bp102c15pdf) describes the key words and phrases medical reviewers are looking for when they review a claim for payment. Medicare requires that specific information is clearly documented for each part of the therapy process for therapy services to be reimbursed. Many other payers of therapy services in adult rehabilitation follow Medicare guidelines when establishing documentation policies for reimbursement.¹⁸ An understanding of these requirements is critical in ensuring reimbursement for services provided. The therapist working with Medicare clients must become familiar with these guidelines and regulations to prevent denial of services. Detailed information can be found at the Medicare Website.

Although its exclusive use is no longer required, Medicare has designed a specific form for outpatient evaluations called the Medicare 700 form, the “Plan of Treatment for Outpatient Rehabilitation.” This form specifies the information required by Medicare. Figure 8-4 shows this form and directions for completing it. Documentation on the initial evaluation must demonstrate that it is reasonable and necessary for the therapist to complete the evaluation to determine whether restorative or maintenance services are appropriate. It is important to fill in all spaces on the 700 form. Failure to complete a section of the form could result in a technical denial. It is important to include a statement of the client’s prior level of function and the change in function that precipitated the occupational therapy referral. Results from assessments that support the need for therapy intervention are recorded in this section. Objective tests and measurements are used to establish baseline data. This information will serve as the basis for short- and long-term goals.

Many rehabilitation companies and hospitals have modified the 700 form with headings and checklists to assist the therapist in providing the type of information that will support the need for therapy services (Figure 8-5). Space on the 700 form is limited, and the therapist must be able to concisely present data that will clearly demonstrate the need for occupational therapy. A recent change in function (a decline or an improvement) is required to justify therapy. The plan of treatment (Section 12) includes functional, measurable goals based on assessment results as described in Section 18. Goals cannot address issues that do not have supporting baseline data in the Assessment section. The plan of treatment is the skilled intervention that the therapist will provide. The 700 form also functions as the end-of-month progress report and/or as the discharge form. Section 20 is completed at the end of the billing period. Progress, current functional status, and skilled interventions provided during the previous month are included here.

Figure 8-6 is an example of an initial evaluation form used in a rehabilitation center. It has been modified to meet the specific needs of the practice setting. Figure 8-7 shows an example of an occupational therapy evaluation report and initial intervention plan that incorporates the OTPF language and process. As facilities update evaluation forms, the OTPF language should be incorporated.

Confidentiality and Documentation

Maintaining confidentiality in documentation is the responsibility of the occupational therapist. Principle 3E of the AOTA Code of Ethics addresses the issue of privacy and confidentiality in all forms of communication, including documentation. “Occupational therapy personnel shall protect all privileged confidential forms of written, verbal, and electronic communication gained from educational, practice, research, and investigational activities unless otherwise mandated by local, state, or federal regulations.”³ Guidelines to the Code of Ethics² speaks directly to confidentiality issues:

Federal laws have been enacted to protect the consumer against breaches of confidentiality. The privacy sections of HIPAA clearly outline the expectations of health care professionals in issues of confidentiality. HIPAA was initially enacted in 1996 and consisted of a series of provisions that required the Department of Health and Human Services to adhere to national standards for electronic transmission of health care information. The law also required that health care providers adopt privacy and security standards by which to protect confidential medical information of patients. Beginning in April 2003, health care providers were required to adhere to the privacy standards mandated by HIPAA. Individually identifiable health information, also known as protected health information (PHI), is federally protected under HIPAA regulations. PHI is health information that relates to a past, present, or future physical or mental health condition. This rule limits the use and disclosure of PHI to the minimum necessary to carry out the intended purpose. It also gives patients the right to access their medical records. This regulation protects the medical records of clients, whether the information is written or electronic (computer) or is verbally communicated. Violations of the HIPAA rulings are subject to criminal or civil sanctions.⁹

The law requires that all staff be trained in HIPAA policies and procedures and understand the implications specific to the work setting. In addition to the client confidentiality procedures explained earlier, safeguards must now be adhered to for compliance with HIPAA regulations. The therapist has a responsibility to protect confidential information from unauthorized access, use, or disclosure. This includes information documented in the medical record. Papers, reports, and forms containing PHI should not be disposed of in the regular trash. Instead they must be shredded. Never leave medical records or portions of records (i.e., therapy notes) unattended in public view. Information (written, verbal, or electronic) cannot be shared with family members unless permission has been provided in writing by the client.

If documentation is done electronically, special care must be taken to prevent unauthorized persons from accessing client information. Log-in pass codes cannot be shared among staff. Therapists must take care to ensure privacy when entering information.

Summary

Documentation is a necessary part of the occupational therapy process. The occupational therapist has a responsibility to the client, to the employer, and to the profession to develop the skills that will allow him/her to accurately document the therapy process. Well-written documentation promotes the profession by providing proof of the value of occupational therapy intervention. It can provide valuable information for outcome research and evidence-based practice. It is a professional expectation that the occupational therapist will keep current on documentation requirements for his/her practice area and will acquire the skills necessary to accurately document the occupational therapy process.

References