DOC 1011 EXAM 2 (CH. 5-10)

SOAP NOTE "A" ASSESSMENT

-DX, THERAPIST RECORDS, CONCLUSION, INTERPRETATION CLIENTS STATUS/DEFICITS ASSESSING WHAT O IS? ARE THEY MAKING PROGRESS? -EX.DECREASE AROM R ELBOW & SHOULDER DUE TO TIGHTNESS

ASSESSMENT "A"

-IN ADDITION THE "P" YOU MAY ALSO IDENTIFY & EXPLAIN INCONSISTENCIES, DISCUSS EMOTIONAL COMPONENTS, DELIBERATE CONTEXTS/NEW ISSUES. -START FIRST BY ASSESSING THE DATA YOU HAVE ALREADY WRITTEN YOUR "S&O".

EXAMPLES USING PERFORMANCE SKILLS(ASSESSING FACTORS NOT WITHIN FUNCTIONAL LIMITS) CH.9

-INABILITY TO SELF-REGULATE ALCOHOLIC INTAKE RESULTS IN DIFFICULTY MAINTAINING EMPLOYMENT. -DEFICITS IN ATTENTION SPAN CREATE SAFETY CONCERNS FOR RIDING A BICYCLE. -DECREASED ORAL MOTOR CONTROL INTERFERES WITH CHILD'S ABILITY TO MANAGE SOLID FOODS.

not capitalized

common nouns in medical terminology -Example: measles, virus, flu, hysterectomy, biceps generic drugs and products -Example: disposable diapers, compression glove, aspirin generic department names-example: an occupational therapy department, rehab department

CORRECT PRONOUN

"THEY (PRONOUN IN PLURAL FORM) WILL HURT 'THEMSELVES'(PRONOUN IN PLURAL FORM) IF THEY (PRONOUN IN PLURAL FORM) LIFT TOO MUCH WEIGHT"

Example of Correct Quotes & Paraphrases?

*-PT STATED, " I DIDN'T SLEEP WELL LAST NIGHT" *-PT STATED THAT HE "DIDN'T SLEEP WELL LAST NIGHT." -PT STATED THAT LAST NIGHT HE DIDN'T SLEEP WELL. *-PT STATED THAT HE SLEPT POORLY LAST NIGHT. -MARY STATED SHE HAS "AN ANCHE IN HER RT HIP" *-MARY STATED, I HAVE AN ACHE IN MY RIGHT HIP." -MARY STATED SHE HAS DISCOMFORT IN HER RIGHT HIP, WHICH SHE DESCRIBES AS AN ACHE. -MARY STATED THAT HER RT HIP ACHES. *-THE CLIENT ASKED, "WILL I BE ABLE TO WALK SOON"? -THE CLIENT INQUIRED IF SHE WOULD SOON BE ABLE TO AMBULATE. *-THE CLIENT ASKED IF SHE WOULD "BE ABLE TO WALK SOON." -THE CLIENT ASKED WHEN SHE WOULD BE ABLE TO WALK AGAIN.

*Example of Incorrect/Errors Quotes & Paraphrases? (missing that, she, inquired) CH. 5

*-PT STATED, "HE DIDN'T SLEEP WELL LAST NIGHT." -PT STATED, HE "DIDN'T SLEEP WELL LAST NIGHT" -PT STATED, I "DIDN'T SLEEP WELL"LAST NIGHT. *-PT STATED " HE SLEPT POORLY LAST NIGHT" -MARY STATED, " I HAVE AN ACHE IN HER RT HIP" *-MARY STATED, I HAVE "AN ACHE" IN MY RIGHT HIP. -MARY STATED " SHE HAS AN ACHE IN HER RT HIP" -MARY STATED "SHE HAS AN ACHE IN HER RIGHT HIP." *-THE CLIENT ASKED "IF SHE WOULD BE ABLE TO WALK SOON." -THE CLIENT ASKED "IF SHE WOULD BE ABLE TO WALK SOON" *-THE CLIENT ASKED, WILL I BE ABLE TO WALK SOON? -THE CLIENT ASKED WHEN WILL I WALK AGAIN?

Examples of "S" Accurate

-CLIENT REPORTED DIFFICULTY WATCHING THE GAME ON TELEVISION LAST EVENING DUE TO DOUBLE VISION. -"I HAD TROUBLE SWALLOWING MY POTATOES. I KEPT GAGGING". -"MY NEW COMPUTER ALLOWS ME TO USE MY MOUTHSTICK MUCH EASIER".

WHAT ARE THE 3 P's ASSESSMENT?

USE THE 3 P'S HELP WRITE THE A - 1. PROBLEMS -2. PROGRESS -3. POTENTIAL

CONFUSING PRONOUN

- JANE(NOUN) AND MARY(NOUN) AGREE THAT HER(PRONOUN) SKILLS ARE IMPROVING. (WHO'S SKILLS ARE WE TALKING ABOUT? JANE? MARY? OR PT? -"THEY (PRONOUN IN PLURAL FORM) WILL HURT 'THEMSELF'(PRONOUN IN SINGULAR FORM) IF THEY(PRONOUN IN PLURAL FORM) LIFT TOO MUCH WEIGHT"

Examples of "S" Inaccurate/Errors CH.6

-CLIENT TALKED ABOUT THE GAME LAST NIGHT. -PT STATED THAT HIS LUNCH TASTED VERY GOOD. -I LIKE MY NEW COMPUTER.

IF A CLIENT IS UNABLE TO COMMUNICATE THE "S" MAY LOOK LIKE?

-CLIENT UNABLE TO SPEAK DUE TO APHASIA. -PT USED NON-VERBAL METHOD (HEAD NODDING) FOR ANSWERING YES & NO QUESTIONS. -RESIDENT DID NOT SPEAK WITHOUT VERBAL PROMPTING.

ADDITIONAL INFO PLAN

-CONTINUE OT 5X WK FOR 1 WK FOR SKILLED INSTRUCTION IN SAFE TRANSFERS AND TOILETING.HOME PROGRAM FOR AROM AND STRENGTHENING EXERCISES FOR RT SHOULDER WILL BE TAUGHT. -REMEMBER THAT THE TIME FRAME YOU CHOOSE SHOULD BE CONSISTENT WITH THE OT TXT PLAN. (SHOULD BE FOUND IN THE EVALUATION)

LAST NOTE PRIOR CLIENT DISCHARGE PLAN (ASSESSMENT)

-"CLIENT WOULD BENEFIT FROM CONTINUED PROM PROVIDED BY CAREGIVER." -"CLIENT HAS BEEN INSTRUCTED IN HOME SAFETY MODIFICATION AND WOULD BENEFIT FROM THE INSTALLATION OF BATHROOM GRAB BARS." -"CLIENT WOULD BENEFIT FROM A PERSONAL EMERGENCY RESPONSE SYSTEM AT HOME FOR SAFETY."

EXAMPLES OF DIRECT QUOTES

-"I HAVE PAIN IN MY RIGHT HIP" . -"I DO NOT NEED THERAPY." -"I CANNOT BRUSH MY TEETH BECAUSE MY WRIST IS STIFF". -" I KEEP HAVING TO GO TO THE BATHROOM SO I WOULD PREFER TO HAVE THERAPY IN MY ROOM". -"I GET FRUSTRATED WITH MY DAUGHTER AND I SCREAM AT HER. I DO NOT KNOW WHAT TO DO ABOUT IT". -"I FEEL LIKE I GET TIRED FASTER THAN I DID 2 WEEKS AGO".

Q. HOW DO YOU OBTAIN VALUABLE INFORMATION FOR THE "S" SECTION?

-CAREFULLY DIRECT THE CONVERSATION TO TOPICS THAT ARE MEANINGFUL TO CLIENT CARE. -THIS ALLOWS YOU TO GATHER INFO THAT IS CRUCIAL FOR PROVIDING QUALITY OT.

SITUATIONS "S" MAY REFLECT CONCERNS, PROBLEMS, IMP INFO CAREGIVERS

-CAREGIVER REPORTS THE CLIENT REFUSES TO WEAR THE SPLINT. -DAUGHTER REPORTS THAT CLIENT FORGETS WHERE THE BATHROOM IS & DOES NOT REMEMBER TO TURN OFF THE STORE -PARENT REPORTED THE CHILD DID NOT SLEEP WELL THE NIGHT BEFORE & CRIED FREQUENTLY IN THE AM PRIOR TO COMING TO TODAY'S SESSION. PARENT UNABLE TO DETERMINE THE CAUSE.

EXAMPLES OF INDIRECT QUOTES

-CHILD REPORTS THAT OTHER CHILDREN MAKE FUN OF HER ADAPTIVE SPOON WHILE EATING LUNCH & SHE DOES NOT WANT TO USE IT. -PT REPORTS COMPLETING HOME PROGRAM TWO TIMES DAILY WITHOUT PAIN & NOTICED THAT SHE IS ABLE TO REACH FOR ITEMS ON HIGHER SHELF THAT SHE WAS UNABLE TO REACH BEFORE. -PT REPORTED THAT HIS DOCTOR ORDERED "SOME HOME CARE FOR A FEW DAYS TO WORK ON TRANSFERS."

EXAMPLES WRITING A USING PROBLEM CH.9 "A"

-Client is concerned regarding deficits in hand function.-Client is still unable to manage fastening independently.

EXAMPLES USING ACTIVITY DEMANDS(ASSESSING FACTORS NOT WITHIN FUNCTIONAL LIMITS) CH.9

-INABILITY TO TOLERATE CLOSED SPACES INTERFERES WITH CLIENTS ABILITY TO USE THE BUS. -CLIENT'S FEAR OF GERMS INTERFERES WITH MONEY HANDLING TASKS AT HIS FAST FOOD JOB. -CHILD'S TACTILE DEFENSIVENESS IS A BARRIER TO COMPLETING PROJECTS IN SCHOOL THAT REQUIRE GLUE. -CLIENT'S HEAT INTOLERANCE HINDERS ABILITY TO RETURN TO HIS OUTDOOR CONSTRUCTION JOB DURING THE SUMMER MONTH.

2. SHOW YOUR SKILL (WRITING "O" OBJECTIVE SECTION) CH.7

-IT IS BETTER TO INDICATE "ACTIVE CLIENT ENGAGEMENT USING NON-PASSIVE WORDS", & THEN CLEARLY IDENTIFY THE SPECIFIC SKILLED OT SERVICES IMPLEMENTED: -SAMPLE: "Client participated in 45-minute BADL session bedside for instruction in compensatory dressing techniques". -SAMPLE: "Client engaged in therapy 45 minutes bedside to facilitate attention to L side during self-care activities." -SAMPLE: "Resident participated in therapy 45 minutes bedside for instruction in adaptive equipment use to increase safety and BADL tasks."LOOK @ TEXTBOOK FOR MORE SAMPLES

CORRECT VERB TENSE

-OTA 'HELPED' THE CLIENT WITH ADLs DURING THE TREATMENT SESSION WHILE THE CAREGIVER 'HELPED' THE CLIENT WITH POSTURAL BALANCE.

WRONG VERB TENSE

-OTA 'HELPED'THE CLIENT WITH ADLs DURING THE TREATMENT SESSION WHILE THE CAREGIVER 'HELPS' THE CLIENT WITH POSTURAL BALANCE.

5. MAKE IT CLEAR THAT YOU WERE NOT JUST A PASSIVE OBSERVER IN THE SESSION(TIPS FOR WRITING A BETTER "O") CH.8

-OTAS DON'T GET PAID TO JUST WATCH A CLIENT DO SOMETHING. -YOUR CHARTING SHOULD SHOW THAT YOU WERE ACTIVELY INVOLVED IN INTERVENTION. -RATHER THAN SAYING: "CLIENT COMPENSATED FOR SHOULDER FLEXION BY LEANING FORWARD WITH WHOLE BODY DURING PREHENSION ACTIVITIES." -YOU MIGHT SAY: "CLIENT REQUIRED SKILLED INSTRUCTION TO AVOID COMPENSATION AT THE SHOULDER DURING PREHENSION ACTIVITIES." -RATHER THAN SAYING: "CLIENT PERFORMED HOME EXERCISE PROGRAM." -YOU MIGHT SAY: "HOME EXERCISE PROGRAM WAS OBSERVED FOR ACCURATE MOVEMENT PATTERNS AND UPDATED TO ACCOMMODATE FOR PROGRESS."

CAPITALIZED

-Proper names in medical terminology =Examples: Parkinson's disease, Babinski sign, Heimlich maneuver, Down syndrome - Trade names of products and medications =Examples: Pampers diapers, Jobst glove, Advil, Velcro, Scotch tape -Specific organizations =Examples: American Occupational Therapy Association

EXAMPLES OF POTENTIAL (WRITING A)

-RESIDENT'S INTACT SENSATION & PRESENCE OF VOLUNTARY MOVEMENT DEMONSTRATE GOOD REHABILITATION POTENTIAL. -CLIENT'S ABILITY TO RECOGNIZE STRESSORS SHOWS GOOD POTENTIAL TO CHANGE MALADAPTIVE COPING STRATEGIES. -STUDENT IMPROVEMENT FROM 50% TO 60% ACCURACY WITH TYPING WORDS USING MOUTHSTICK INDICATES GOOD POTENTIAL TO MEET GOALS STATED IN IEP. -PT.'S ABILITY TO RECALL & DEMONSTRATE 3/3 TOTAL HIP PRECAUTIONS SHOW GOOD POTENTIAL TO FOLLOW HIP PRECAUTIONS AFTER DISCHARGE.

EXAMPLES USING CLIENT FACTORS(ASSESSING FACTORS NOT WITHIN FUNCTIONAL LIMITS)

-RT SHOULDER PAIN INTERFERES WITH CLIENTS ABILITY TO PERFORM SLIDING BOARD TRANSFERS. -LYMPHEDEMA IN RT ARM HINDERS CLIENT'S ABILITY TO REACH INTO UPPER KITCHEN CABINETS. -EXCESSIVE TONE IN LT UE INTERFERES WITH INFANT'S ABILITY TO CRAWL.

POTENTIAL WRITING A

-SHOWS CLIENTS POTENTIAL FOR SUCCESS IN REHABILITATION

EXAMPLES USING PERFORMANCE PATTERNS PG 136

-STUDENT'S ROUTINE OF EATING PIZZA & MILKSHAKES EVERY DAY FOR LUNCH CONTRIBUTES TO HIS WEIGHT GAIN, WHICH HINDERS GYM CLASS PARTICIPATION. -CLIENT'S COMPULSIVE HABITS OF CHECKING LOCKS EXCESSIVELY IN THE MORNING INTERFERE WITH GETTING TO WORK ON TIME LOOK @BOOK MORE EXAMPLES

WRITING THE "P" CH.10

-THE FINAL SECTION OF A SOAP NOTE. -IT LISTS THE SPECIFIC TREATMENT PLAN TO BE USED TO ACHIEVE THE OT GOALS. -YOU WILL RECORD WHAT FOLLOW UP IS REQUIRED -EX. WHAT YOU PLAN TO DO IN THE CLIENTS NEXT SESSION/WHAT NEEDS TO BE ADDRESSED IN THE NEAR FUTURE. -THE "P" MIGHT ALSO BE A RECOMMENDATION THAT YOU WANT THE CLIENT, FAMILY/CAREGIVER TO FOLLOW THROUGH WITH-EX. INSTALL GRAB BARS, DO HOME EXERCISE PROGRAM ETC.

EXAMPLES USING CONTEXT & ENVIRONMENT CH.9

-THE SOUND OF SIRENS TRIGGERS FLASHBACK OF CLIENT'S ACCIDENT AND INTERFERES WITH TASK COMPLETION AT WORK. -LACK OF ELEVATOR ACCESS IMPEDES CLIENT'S ABILITY TO ENTER HIS OFFICE. -UNAVAILABILITY OF PUBLIC TRANSPORTATION LIMITS CLIENT'S ABILITY TO OBTAIN GROCERIES

QUOTES & PARAPHRASING

-THERE ARE MULTIPLE OPTIONS WHEN DOCUMENTING WHAT YOUR PATIENT SAYS. 1.DIRECT QUOTES USING FIRST-PERSON TENSE: THE CLIENT STATED, "I WILL NEVER BE ABLE TO GO BACK TO WORK." 2.DIRECT QUOTES USING THIRD-PERSON TENSE: THE CLIENT STATED THAT HE "WILL NEVER BE ABLE TO GO BACK TO WORK" 3.A COMBINATION OF QUOTES & PARAPHRASING: THE CLIENT STATED THAT HE "WILL NEVER BE ABLE TO GO BACK TO WORK" BECAUSE HE CONSIDERS HIS JOB TOO STRESSFUL. 4.PARAPHRASING ONLY: THE CLIENT EXPRESSED DOUBTS ABOUT RETURNING TO WORK

SOME FACILITIES REQUIRE THE "P" TO INCLUDE GOALS

-THOSE GOALS SHOULD FOLLOW THE OT's INTERVENTION PLAN. -THE GOALS SHOULD DEPICT THE INCREMENTAL STEPS TO ESTABLISHED LONG-TERM/STG. -IN A SETTING SUCH AS A SCHOOL SYSTEM WHERE MONTHLY NOTES ARE WRITTEN, YOUR GOAL IN THE "P" MIGHT BE WHAT YOU HOPE TO ACCOMPLISH IN THE NEXT MONTH. -IN A SNF, IT MIGHT BE YOUR GOAL FOR THE NEXT WEEK. -IN AN ACUTE CARE SETTING, IT MIGHT BE YOUR GOAL FOR TOMORROW

EXAMPLES PLURAL & POSSESSIVESslide 13-15 PPT#3/CH.5

-The OT's each supervised two OTA's. -The client's rt hand was minimally edematous .-The patient's commode was placed next to his bed. -The client's charts were in the file cabinet. What is a direct

5. MAKE YOUR NOTES PROFESSIONAL, CONCISE, & SPECIFIC CH. 7

-USING APPROPRIATE LANGUAGE WILL MAKE YOUR NOTES SOUND MORE PROFESSIONAL. EXAMPLE #1 -RATHER THAN SAYING: "RESIDENT FLOPPED DOWN ONTO THE BED SOB, CLOSED HE EYES, AND MOANED. RESIDENT RECLINED IN BED WITH MIN A TO POSITION HERSELF." -YOU MIGHT SAY: "CLIENT OBSERVED TO BE FATIGUED FOLLOWING THERAPY SESSION & REQUIRED MIN A FOR POSITIONING IN BED." EXAMPLE#2 -RATHER THAN SAYING: "VETERAN GRABBED ONTO THE TRAPEZE & USED IT IN ORDER TO SIT UP." -YOU MIGHT SAY: "SUPINE → SIT USING TRAPEZE." EXAMPLE #3 -RATHER THAN SAYING: "CLIENT PUT THE BOARD IN PLACE TO MAKE A SLIDING BOARD TRANSFER." -YOU MIGHT SAY: "CLIENT POSITIONED SLIDING BOARD FOR TRANSFER."

PROGRESS (WRITING A)

-Verification that treatment provided is effective -statement that previous goals have been met/changed -reasons for lack of progress

EXAMPLE WRITING A USING PROGRESS CH. 9 "A"

-client is able to understand and integrate therapy tasks. -client is able to use adaptive equipment to compensate for adl deficits. -client is willing to follow through with home program.

PROBLEM WRITING A

-safety risks -inconsistencies btwn client report & objective findings -factors not w/in functional limits can be influences by ot interventions

EXAMPLES INCLUDE GOALS "P"

1. FREQUENCY 2. TO WORK ON WHAT 3.OCCUPATION 4.FOLLOW UP (MAYBE) -P: Continue one hour daily sessions for 2 weeks to improve motor planning skills for dressing. By the end of next session, vetern will demonstrate the ability to identify front and back of shirt with one verbal cue. (This last sentence exemplifies a goal requirement if needed.) -P: Clients will continue to be seen in values clarification group 3x/wk for 2 weeks to address low-self-esteem and alcohol use. Pt will demonstrate awareness of self-help strategies by verbalizing three alternatives to handle stress rather than drinking, within two group sessions.

Often Words Mistaken for CH. 5

1.AID(MEANING=TO PROVIDE ASSISTANCE) 2.THERE(A LOCATION TERM: "OVER THERE" 3.DYSPHASIA(DIFFICULTY SPEAKING)

Using Common Words Correctly

1.AIDE(AN ASSISTANT/HELPER; AS IN REHAB AIDE) 2.THEIR(BELONGING TO SOMEONE) 3.DYSPHAGIA(DIFFICULTY SWALLOWING)

(5) GUIDELINES FOR WRITING GOOD "O" OBSERVATIONS PG.94-97 "participated, engaged, performed" CH.7

1.BEGIN WITH STATEMENT ABOUT THE SETTING & PURPOSE OF THE ACTIVITY "client participated xminutes, what setting, purpose txt, & expected functional gain" 2.SHOW YOUR SKILLS "active engagement non-passive words" 3.ORGANIZATION OF THE "O" "chron/categories" 4.DONT DUPLICATE SERVICES "make sure ot specific/int" 5.MAKE YOUR NOTES PROFESSIONAL, CONCISE, & SPECIFIC " rom, prom, cues, assist etc"

9 TIPS FOR WRITING A BETTER "O"CH.8

1.FOCUS ON FUNCTION 2.WRITE FROM THE CLIENT'S POINT OF VIEW AND VOID MENTIONING YOURSELF 3.FOCUS ON CLIENT'S RESPONSE TO THE INTERVENTION RATHER THAN ON WHAT THE OTA DID 4. DE-EMPHASIZE THE TREATMENT MEDIA 5.MAKE IT CLEAR THAT YOU WERE NOT JUST A PASSIVE OBSERVER IN THE SESSION. 6.AVOID JUDGING THE CLIENT (EVEN THOUGH YOU ARE MAKING PROFESSIONAL JUDGEMENTS) 7.BE SPECIFIC ABOUT ASSIST LEVEL 8.USE STANDARDIZED TERMINOLOGY TO DESCRIBE AND GRADE YOUR TREATMENT ACTIVITIES 9. DOCUMENT PAM PROPERLY

What does subjective mean?

INFO REPORTED BY THE CLIENT/CAREGIVER.(HX, LIFESTYLE, EMOTIONS, CLIENT GOALS, COMPLAINTS TO INTERVENTION)-EX.

What is an indirect quote?

IS A PARAPHRASE/SUMMARY OF WHAT THE CLIENT REPORTED

What is a direct quote?

IS THE ACTUAL REPORT OF THE CLIENTS CONCERNS, LIMITATIONS, & PROBLEMS -EX. PAIN, FATIGUE, ATTITUDES, GOALS, PLANS ETC.

WRITING THE "PLAN"

THE "P" MUST HAVE 1. SPECIFY THE FREQUENCY & DURATION OF OT TREATMENT. 2.TELL WHAT YOU WILL BE WORKING ON DURING THAT TIME TO ADDRESS THE CLIENT'S NEEDS. 3. RELATE TO A PERFORMANCE SKILL/ARE OF OCCUPATION & CLIENT'S OT GOALS 4.INDICATE ANY OTHER PERTINENT FOLLOW-UP NEEDED FOR THE CLIENT'S PRESENT SITUATION. -CONSUMER WILL CONTINUE PREVOCATIONAL PROGRAM 5 DAYS/WK. IN ORDER TO ↑ TASKS BEHAVIORS FOR WORK SUCH AS CORRECT USE OF TIME CARD & TIME MANAGEMENT DURING BREAKS.

1. BEGIN WITH STATEMENT ABOUT THE SETTING & PURPOSE OF THE ACTIVITY (WRITING "O" OBJECTIVE SECTION) CH.7

USE THE FOLLOWING TEMPLATE AS A GUIDE:-CLIENT PARTICIPATED IN __________-MINUTE SESSION IN (IN WHAT SETTING) FOR (PURPOSE OF TREATMENT SESSION.) -SAMPLE: Client participated in "45"-minute session "bedside" for instruction in compensatory dressing techniques. -SAMPLE: Client engaged in 30-minute OT session in classroom to improve ability to use computer keyboard in class. SAMPLE: Client participated in 30-minute cooking group in OT kitchen for skilled instruction in compensatory techniques for meal preparation.

JUSTIFYING CONTINUED TREATMENT CH.9 "A"

YOU CAN JUSTIFY CONTINUED OT TREATMENT BY ENDING YOUR "A" SECTION WITH THIS SENTENCE: "CLIENT WOULD BENEFIT FROM.." -THEN BASED ON YOUR OBSERVATIONS & ASSESSMENT, COMPLETE THE SENTENCE WITH A JUSTIFICATION OF CONTINUED TO TREATMENT. "RESIDENT WOULD BENEFIT FROM ENVIRONMENTAL CUES TO ORIENT HIM TO ENVIRONMENT"