Begin with Activity AnalysisÂ
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Download the pdf for âActivity Analysis Client Educationâ to help your clients make sense of the occupational therapy mindset! It is hard to conceptualize a concept that is unique to one profession, so show them! Show them the power of a continuum.
Show them that you know all about the human anatomy! This is how we change the face of the profession!!
Take your treatment planning and patient education to the next level by using this colorful tool to explain your profession
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***Color-Coded Activity Analysis Copyrighted and Trademarked by Buffalo Occupational Therapy***
Real Examples of Common Rehabilitation Documentation
Check out some examples of documentation used in a clinical setting across a full continuum of care. This is one example and often changes based on the setting you are in.Â
The Examination and Evaluation will change based on the DiagnosisÂ
The Examination and Evaluation process in occupational therapy will change based on the specific diagnosis. Each condition presents unique challenges and requires a tailored approach to accurately assess and address the patient's needs. By adapting our evaluation methods to the diagnosis, we ensure that we gather relevant information, develop appropriate treatment plans, and provide the most effective care possible. This individualized approach is essential for achieving the best outcomes and enhancing the quality of life for our patients.
Check out the printouts available for you!The Difference Between Evaluation, Progress Notes, and Re-Certification
Initial Evaluation: An initial evaluation is the first assessment conducted when a person begins receiving healthcare services. It is a comprehensive evaluation performed by a healthcare professional, such as an occupational therapist, to gather information about the individual's condition, abilities, and goals. The evaluation involves gathering medical history, conducting tests or assessments, and establishing a baseline for future comparison. The purpose is to determine the person's needs, develop a treatment plan, and set goals for therapy.
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Progress Note: A progress note is a documentation that captures the ongoing progress of a person's healthcare journey. It is typically recorded at regular intervals to document the individual's response to treatment, changes in their condition, and the effectiveness of interventions. Progress notes may include observations, assessments, treatment provided, modifications made to the treatment plan, and any relevant discussions or recommendations. These notes help track the person's progress over time, inform future treatment decisions, and ensure continuity of care.
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Recertification Note: A recertification note is a document that occurs when the need for continued therapy or services is reassessed. It is often required by insurance companies or regulatory agencies to justify the ongoing need for care. The recertification note includes updated information about the person's condition, progress made, and the current treatment plan. It may also involve re-evaluating goals, determining the necessity for further therapy, and justifying the need for continued services based on the person's functional status and medical necessity.
Writing Notes and Goals
Writing Goals for Initial Evaluations, Treatment Notes, Progress Notes, and Discharge Planning is an art form. Over time, you develop stronger skills.Â
Occupational Therapy 101
Watch the playlist with foundational themes for occupational therapy practice.Â
