Documenting functional outcomes.
نویسندگان
چکیده
The American Journal o/Occupalional Tberap)' At the level of individual patient care, the outcomes of occupational therapy practice are evident in documentation. Reichenbach commented that "documentation not only paints a picture of the client, but a picture of what occupational therapists do and how we do it and of our anticipated hopes for the client's future" (1993, p. 5). Health care payers require treatment goals to be measurable and directly relevant to function. Furthermore, changes in function after treatment must be clearly stated. This case report is presented to illustrate functional outcomes and is presented in the form of documentation. After the presentation of the initial evaluation, assessment, and follow-up note is a discussion of the format used for note writing. This case involves a man potentially at risk due ro unmet functional dependency needs. The patient was referred to occupational therapy by a geriatric psychiatrist in an outpatient clinic for older adults. In this serring, the occupational therapist is authorized to make up to two home visits. Additional horne visits require further authorization. Patients are contacted by teJephone to monitor compliance with recommendations. In the event that a patient is found ro be at significant risk in his or her liVing situation, the occupational therapist, in conjunction with the patient's physician and social worker, will contaer protective services. Hence, occupational therapy documentation may be used to initiate and support legal action.
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ورودعنوان ژورنال:
- The American journal of occupational therapy : official publication of the American Occupational Therapy Association
دوره 48 10 شماره
صفحات -
تاریخ انتشار 1994