400907 Lecture Notes - Lecture 3: Medical Record, Jargon, Occupational Therapy
22 Jun 2018
School
Department
Course
Professor
Week 3 - documenting an occupational profile
LEC
Why documentation is so important
Legal requirement
Record or goals and outcomes of intervention
Communicate with other team members
Record of clinical reasoning
Record of each episode of care, including all interactions, interventions and
occasions of service
Introduction to health records
Formal document
Health record number, date time of entry being made
Label your profession
Print and sign your name
Write your designation (Occupational Therapy Student)
Either paper or electronic
What do you expect to find in a health record?
Admission/intake/referral to the service -> evaluation/assessment/diagnosis -> re-evaluation ->
handover/ transfer/ discharge from the service
Admission / Intake / Referral
Why is the client here? What is the problem?
Presenting problem/reason for referral
Priority
Other referral information
First observations and tests/measurements/initial assessment
Plan
Assessment
What is the problem? What are the issues contributing to the problem?
Evaluation and assessment for occupational therapy
Interview and initial assessment
Standardised assessment
Non-standardised assessment
Depending on the setting, may involve a multi-disciplinary team
Treatment / Intervention
Everything that is done by a health professional must be documented, including every contact with
the client + any contact with other health professionals about the client
Must document;
What
How
When
By whom
For occupational therapy
All treatment/intervention sessions and contact with client
Clinical reasoning
Plan
Family conferences/liaison with significant others
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Record of each episode of care, including all interactions, interventions and occasions of service. Health record number, date time of entry being made. Admission/intake/referral to the service -> evaluation/assessment/diagnosis -> re-evaluation -> handover/ transfer/ discharge from the service. Depending on the setting, may involve a multi-disciplinary team. Everything that is done by a health professional must be documented, including every contact with the client + any contact with other health professionals about the client. Make yourself a guide for screening a health record and take it with you to placement. Ask about abbreviations that you do not understand. Must only use black pen - red pen is used for allergies - green pen for audits. Always place patients full name , dob and medical record number (mrn) on the. Front and back of each medical record sheet. Always date and time every entry using 24hr time e. g. 9/9/2017 1245hrs.
