Documentation Guidelines
When you write something in error in a patient's medical record, how do you correct it?
draw a single line through the entire entry and initial it/sign it
What does COAST stand for?
Client, occupation, assist level, specific conditions, time line
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
What is an EHR and EMR, are they the same?
EHR- Electronic Health Record
EMR- Electronic Medical Record
Yes they are the same
What are red flag words?
maintain, continue these words suggest progress is not occurring and could impact reimbursement
Client will complete toilet transfer with minimal assistance with the use of a bedside commode in 1 week
What is the specific condition?
use of a bedside commode
Give an example of an S statement
"I can't wait to take a shower today"
What are some advantages of EHR?
Quicker, easily read by all, can be accessed across a healthcare network
What is an advantage and disadvantage of abbreviations?
advantage- saves time
disadvantage- limit readers understanding
Give an example of an ADL COAST goal
Give an example of a P statement
Continue with OT treatment daily for 30 minutes to address education on the newly obtained shower bench and bathing independence
What are some disadvantages of EHR?
Technology changes rapidly, expensive, sometimes it does not work, training time
Occupational therapy documentation should always include the following...
the services provided, signature and date, the reason for the skilled need
Client will improve grip strength by 3# as measured by the dynamometer in 2 weeks.
What part of the COAST goal is missing
Occupation!!!
Give an example of an O statement
The patient participated in 30 minute OT session in inpatient rehab for toileting training using newly obtained raised toilet seat.
What are some best practices of EHR?
greet the client, make eye contact, explain the use of EHR, be mindful of the position of the screen
Documenting in a timely manner means what?
Documenting as closely to the time of service as possible, preferably point of service documentation
Client will complete toileting skills using bedside commode in 5 days.
Is this COAST goal complete?
assist level
Give an example of an A statement
The client demonstrated unsafe transfer practices using a transfer tub bench during shower transfer training.
What is meant by loss of the narrative in EHR?
just clicking away and not telling an individualized story about your clients