Documentation Requirements For Occupational Therapy - OCDE

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“An occupational therapist shall documenthis or her evaluation, goals, treatment plan,and summary of treatment in the patientrecord. (BPC § 2570.185)”Guidelines for Occupational Therapy and Physical Therapy in CaliforniaPublic Schools, 2nd Edition. 2012.

“The patient record shall be signed legibly and shall indicate actualcare provided to a patient including the date and nature of the servicesprovided and the name, title, and role of any person providing service. ““Specifically, a Physical Therapist must document in the patient recordthe following: examination and re-examination, evaluation and reevaluation, diagnosis, prognosis and intervention, treatment plan andmodification of the plan of care, each treatment provided by thephysical therapist or a physical therapy aide, and a discharge summary(16 CCR § 1398.13).”Guidelines for Occupational Therapy and Physical Therapy in California Public Schools2nd Edition. 2012

B. Service Contacts1. Documents contacts between the client and the occupational therapy practitioner.Records the types of interventions used and client’s response, which can includetelephone contacts, interventions, and meetings with others.2. Suggested content:a. Client information—Name; date of birth; gender; and diagnosis, precautions,and contraindicationsb. Therapy log—Date, type of contact, names/positions of persons involved, summary orsignificant information communicated during contacts, client attendance and participationin intervention, reason service is missed, types of interventions used, client’s response,environmental or task modification, assistive or adaptive devices used or fabricated,statement of any training education or consultation provided, and the client’s presentlevel of performance. Documentation of services provided should reflect the complexityof the client and the professional clinical reasoning and expertise of an occupationaltherapy practitioner required to provide an effective outcome in occupationalperformance. The client’s diagnosis or prognosis should not be the sole rationale for theskilled interventions provided. Measures used to assess outcomes should be repeated inaccordance with payer and facility requirements and documented to demonstratemeasurable functional progress of the client.c. Intervention/procedure coding (i.e., CPT ), if applicable.

VISIT/ENCOUNTER Documentation of each visit/encounter shall include the following elements:o Patient/client self-report (as appropriate).o Identification of specific interventions provided, including frequency, intensity,and duration as appropriate. Examples include: Knee extension, three sets, ten repetitions, 10# weight Transfer training bed to chair with sliding board Equipment providedo Changes in patient/client impairment, activity limitation, and participationrestriction status as they relate to the plan of care.o Response to interventions, including adverse reactions, if any.o Factors that modify frequency or intensity of intervention and progressiongoals, including patient/client adherence to patient/client-related instructions.o Communication/consultation with providers/patient/client/family/ significantother.o Documentation to plan for ongoing provision of services for the next visit(s),which is suggested to include, but not be limited to: The interventions with objectives Progression parameters Precautions, if indicated

“If you did not document it, it did not happen” Meet professional standards for the servicesprovided Must align with present levels and goals of studentas listed in IEP Must be relevant to the IEP goals or diagnosis Auditors like to see documents that can standalone Answer the questions: What?, Why?, How Much?,Response? and Additional Action?LEA Provider Manual Reference: (loc ed a prov)

For LEAs to receive Medi-Calreimbursement: A child must be Medi-Cal eligible The service must be covered by Medi-Cal The service must be medically necessary with aphysician’s prescription The service provider must have the requiredlicense or other credential/qualification

Medi-Cal Billable Services- IndividualMedi-Cal Non-Billable Services- Consultation- Collaboration- Group

Defining “Individual Service” Medi-cal vendors can interpret individualservices differently Interpretations- 1:1 interaction between student/therapist, noadditional students- 1:1 interaction between student/therapist in a smallgroup setting of 2-3 students

Medi-Cal Update SPA- State Plan Amendment- Contract between state and federal government- Thru a SPA, Group OT treatment could be abillable service in the future in the state of California- Department of Healthcare Services currentlylooking into this

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Leader Services/CAMRA


Some districts also use written notes/logs tocoincide with their Medi-Cal documentation Those districts that do not use Medi-Cal softwareuse written notes only Variety-Treatment NotesLogsCollaboration/Consultation Forms

ess/TreatmentNotesXUsing imSELPATustinNewportMesaAnaheim CityWOCCSEOCDEGoogleSheetsXXXXXXXXX


Provide oolProgramHomeProgramTeamSupport/CollabDecide whowill maintainAdaptiveEquipmentStandardized scoresCommunity ion w/ ParentsPlanningTestEducationBegins atinitial evalGoals

Meeting IEP goals related to area of service Reached maximal potential Needs can be managed by: educationalteam, another service provider Deficits don’t interfere with functioning atschool Classroom accommodations, modifications,supports meet needs Therapy is contraindicated due to medical orphysical status Student reaches twenty two years of age

ReferencesAmerican Occupational Therapy Association. (2008). Occupational therapy practiceframework: Domain and process (2nd ed.). American Journal of Occupational Therapy,62, 625-683.American Occupational Therapy Association. (2013). Guidelines for Documentation ofOccupational Therapy. American Journal of Occupational Therapy, 67 (6), S32–S38.American Physical Therapy Association. (2009). Guidelines: Physical Therapy Documentation ofPatient/Client Management. tMgmt.pdfGuidelines for Occupational Therapy and Physical Therapy in California Public Schools, 2nd Edition.2012.LEA Provider Manual Reference: (loc ed serv .aspx

(2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683. American Occupational Therapy Association. (2013). Guidelines for Documentation of Occupational Therapy. American Journal of Occupational Therapy, 67 (6), S32-S38. American Physical Therapy Association. (2009).

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