occupational therapy discharge summary

Functionally, a discharge summary (a.k.a. Rafael has met his occupational therapy goals. If you have any questions about this case, or have any ideas or requests for future cases, contact the Practice Resource Service: 1.800.890.6570/416.214.1177x240 or [email protected] Kendra carefully documents all communications with Rafael including her discharge note, which includes: client status, reason for discharge, when the occupational therapy service was initiated, summary of outcomes, discharge recommendations, and date of discharge. Occupational Therapy Discharge Summary Canvas April 21st, 2019 - This physical therapy form includes fields related to discharge planning such as patient information long term goals admission and discharge status reason discharge additional comments and discharge instructions As an First Name . Date of Exam: 7/4 /2012 Time of Exam: 7:14:10 PM. This is from 372.1 (f) Discharge. ☐ Phyisician notified of discharge summary availability ☐ Scheduler notified ☐ Private services offered ☐ Order and summary completed ☐ Report given to assuming agency with Advance Directive Status Other: Discharge Disposition ☐ Discharge to Home Exercise Program! Occupational Therapist – Weekend Discharge Team – Temporary Part-Time (192231) Toronto, ON, CA Posted: 1/14/2020 9:40:09 AM. OTs should attempt to contact clients verbally and/or in writing to discuss any concerns relating to the provision of service. OT Discharge Summary Page 1 of 1 Revised: 03/2012 Occupational Therapy Discharge Summary Patient’s Last Name . After working with Rafael on activity modification and upper extremity strengthening for approximately three months, Kendra confirms Rafael has achieved his occupational therapy goals. All instructions were given. x�\һmCAD�V�?��*��S�%(ܿa݉�ar"Z�km_6�v���y���Z_���c��Z�ɼs.bd�C�I�rP��8��8��8��8��8J�J�J�J�J�J�$J�$J�$J�$J�$J�J�J�J�J�J�4J�4J�4J�4J�4ʠʠʠʠʠ�]�j�V��j���ڪ. Patient Sex – se… Kendra reviewed the applicable College documents: After reviewing section 7 of the Professional Misconduct Regulation, Kendra understands it can be considered professional misconduct to discontinue services “…that are needed unless the discontinuation would reasonably be regarded by members as appropriate having regard to: the member’s reasons for discontinuing the services, the availability of alternate services, and, the opportunity given to the client to arrange alternate services before the discontinuation.”. Kendra asks Rafael if he would like to proceed with the remaining sessions to support his return to work and if he does not wish to continue, he will be discharged from occupational therapy services. He tells Kendra he will contact her if he decides to return to the clinic. The patient was afebrile. �� ���H�xY��E�����Y��okx��xZ��~�����o��뛧��k�W��]_���j]�w}ez�]_��g��������v�3�� ������ґ� �u�x:���O�;��RO4:]?��x�����i���~�6F��y�����vfG���G_3��},>��YRm;A���'nO66eg�e���O��8�����B�����៏�ͅ��SlN��-ǛmNt鼍����Ó�cl����G��;X��z���UW��-tq=���ƛh�Y\Ւo�_qo?�~}�0�����a��+�s�I An occupational therapy home assessment soon after the patient returns home from hospital can help to identify any unexpected difficulties that may arise, ensure the patient is safe and supported at home. • The occupational therapist must document a discharge summary at the discontinuation of services. Ҿ��a�G_�.�s��x��L���+_����#�=͎Q'/�Q����;����-IN�)F������`�tl늭^��@��!x?� �+�z�6olG���"�D��JǶ��֝�1��?J?�&��z̶mlGi�ѿ�����P���۲�=F���oP�zrŶ�մ����q���]%ӱ�+�yg[�^����쯴�_M�r"խOyM|ڶ ov�v��ˋ9w�����os|�����uk��\/k�N�C� R�c�b/~��5�� �Cԕ���8c4ѱQ�n�Q//��O�p[j����؅�-ضY�î��m>�v������ 6`� Kendra, an occupational therapist (OT), receives a referral from an employer to assess Rafael’s ability to return to work. Discharge Evaluation: Right 67 lbs. OTs should use their clinical judgement to consider the level of risk for the occupational therapy service that is provided and the potential implications of discontinuing service. xڔY��$� ����%Q��@��6��SÇ��Lv����}%VWgg�G:���z�#YjI��r�ȁk ��5Pˁ[`��F�BJ%$�Є� x�$H�!�Y� Important information to include regarding the patient includes: 1. Discharge Report—Summary of Occupational Therapy Services and Outcomes 1. Job Summary The occupational therapist is responsible for empowering patients to participate more fully in daily tasks when this ability is compromised by a health condition. OTR/L is responsible for the supervision of the care provided to specific patients by the COTA. The patient will have ongoing PT, OT services and arrange through the Private Community Team. What is a discharge summary? Patient Address –the usual place of residence of the patient 5. Kendra wonders if she should discontinue her occupational therapy services. Currently serving patients in acute care completing evaluations to recommend best interventions and discharge plans for patients; Previously primary Occupational Therapist on Brain Injury Team for 3.5 years occupational therapy aide is trained by an occupational therapist or occupational therapy assistant to perform specifically delegated tasks. ... Summary/Analysis 34. CL489N (082019) Occupational Therapy Discharge Report Page 1 of 8 Occupational Therapy Discharge Report If applicable, please select the Lock button before submitting the form. Problem Pertinent Review of Symptoms/Associated Signs and Symptoms: Psychotic, depressive, and anxiety symptoms are denied. ☐ Discharge Occupational Therapy ONLY! 246 0 obj <>stream These may include: Patient Name – full name of the patient (also the patient’s preferred name if relevant) 2. To complete a discharge note, the licensed therapist must detail the conclusion of a patient’s care and his or her subsequent discharge. The patient was prescribed home health nursing, physical therapy, occupational therapy and aide. Can an occupational therapy assistant (OTA) perform a discharge summary? (Category - Licensure/Administrative) 4. This Occupational Therapy Discharge Summary Mobile App is designed to make it easy for occupational therapists to document patient discharge from therapies. She attempts to contact Rafael again by phone, leaves a voice mail, and sends him a letter outlining a timeframe for him to contact the clinic, beyond which his file will be closed and he will be discharged. Kendra knows the refusal to proceed with the remaining occupational therapy sessions is not grounds alone for discontinuation and she must make reasonable attempts to understand or clarify the client’s reasons for declining to proceed. Unexpected discontinuation of services can be complex and sometimes challenging. X ��P What are the continuing education requirements? Occupational therapy is medically prescribed and involves skilled evaluation, treatment, and discharge. 06/2017 - Current Occupational Therapist | Wake Forest Baptist Medical Center - Winston-Salem, United States. %PDF-1.6 %���� 1. The OTA or COTA may collect the information for those patients he/she is working directly with and write it down. y�݅,���2C=g�ߜ�kH�I{@o�������/)G0��Dɴ�����\w�EI��. He asks Kendra for a copy of his clinical record. Extra curricular activities, Community or outpatient therapy goals, notes on staff; Equipment or accommodations; Anticipated discharge plans; Dated and signed by practitioner with professional credential (CCC-SLP, OTR/L, PT, MPT, etc.) {ٻ��?��9���a�fo\D{�/�����X�*^�^£����XɃ����Q�KW�U�Kq�t,8 Just as in the Plan of Care, the occupational therapist can assign to the �#DN*�������d`XVK�,�yB�H�6�d3����2����^�~���e)�$HV)��,� d�+=�.b+Ĝ�r�3D#���ݸ����\�U-,�d�������^��f��i���ʹ�䍦~��va��[X�"���"��.bEb�b ������/@��+uQ�b��(مUr��ץY��Gij(�haQ�"��[email protected]��H4T".�5 mQ �$���ɨ���"�w*.,��2�A���*� Apply for position. The final sessions are to support gradual return to work. DISCHAGE SUMMARY. She recommends he start returning to work on a gradual basis with modified hours and adaptive equipment. Initial Evaluation: 5 lbs. If required, an OT will assist by linking patients to further supports. Job Summary. Why OT at Hospital Discharge? MI : HICN: Certification Period ; From: Through: # of Visits (Including Eval) Date of Discharge . ��DBˀ ���1GX�؀�Mi�xf�D�����r� Kendra examines her organization’s policies and procedures that relate to discharging clients. BILATERAL COORDINATION. Rafael is a worksite manager whose duties include: sitting at a desk to complete administrative tasks, walking to the warehouse for quality control checks, and lifting light equipment. ‘Only an occupational therapist has the authority to discharge patients from occupational therapy services, §372.1 (f) Discharge. physical therapist or a physical therapy aide, and a discharge summary (16 CCR § 1398.13).” Guidelines for Occupational Therapy and Physical Therapy in California Public Schools First Name : MI : HICN: Certification Period ; From: Through: # of Visits (Including Eval) Date of Discharge . Kendra is planning to discuss the implications of not proceeding with the remaining sessions and discuss options. The occupational therapy assistant may contribute to the discharge summary; however, the final responsibility for the documentation and the signature and credentials on the report must include that of the occupational therapist. average, left 59 lbs. Discharge Evaluation: 10 lbs. Sign up to stay up to date and receive the latest cases when they’re released. Kendra does not want to abandon Rafael, however, when he misses his sessions without any notification, other clients on the waitlist are negatively impacted. hospital discharge); AND/OR . Features Signature Capture Robert’s mother reported that there were no complications with his birth, and that he has a diagnosis of Sensory Processing Difficulty 782.0 and Pervasive Developmental Disorder 299.9. ... July 2010. Clinician's Narrative, and 4. OT Discharge Summary Page 1 of 1 Revised: 10/2009 Occupational Therapy Discharge Summary Patient’s Last Name . DATE ADMITTED : 3/12/2012 DATE DISCHARGED : 7/4/2012. Discharge: Having completed his rehab, the patient was discharge to home with CCAC in place but awaiting long-term care placement. Kendra wonders if she should discharge Rafael based on his poor attendance and the deterioration of the client-therapist relationship. Directs responsibility for the contents of the discharge Evaluation/summary. She discusses the risks and implications associated with discontinuing service including her need to report his lack of participation to the employer. We currently have a Temporary Can occupational therapy assistants (OTAs) complete home assessments? Alanah’s Alluring Pastries would like to acknowledge and reward ALL children who have received occupational therapy (OT) services with AOTS, PLLC and expected to be discharged. {�J(�W�Ac�4I�@�=��\(����8p#� Lp� ^��a�~ � [X�5N�Kr�!�QaO��~�"g�Qa����?�*�P If services must be discontinued, the client should be given as much notice as possible. The Initial Assessment, 2. 7.8.4 Discontinuation, Reinstatement and Discharge From Services 04/94 - Effective 01/14 - Reviewed 01/14 - Revised Discontinuation, Reinstatement and Discharge from Services Purpose This document outlines the process of discontinuation and reinstatement of Occupational Therapy and Physical Therapy. DISCHARGE STATUS AND INSTRUCTIONS Final Exam, Interval History Ms. Nesmith's behavior has been stable and uneventful and she denies any psychiatric problems or symptoms. DATE OF ADMISSION: MM/DD/YYYY. average . This discharge summary consists of. 3. The patient was also given a wheelchair. Kendra wonders if Rafael understands the implications of not attending his occupational therapy sessions and if she has an obligation to continue to treat him. The American Occupational Therapy Association advances occupational therapy practice, education, and research through standard setting and advocacy. THERAPY CONTENT/CLINICAL SUMMARY: discharge note) is a progress note that covers the reporting period from the last progress report to the date of discharge. Over the next few weeks, Rafael misses several sessions with Kendra, which were intended to support his return to work and finalize discharge arrangements. The COTA may not carry out the initial OT evaluation, develop the care plan, secure DR orders, or independently discharge the patient. While at work, Rafael suffered a slip and fall accident. Vital signs were stable. Provides Occupational Therapy Services for individual patients according to the principles and practices of Occupational Therapy. She explains that he can resume his occupational therapy sessions once he is ready, however there is a possibility he will be placed on a waitlist. A. Prevention of falls should be a key item to be addressed in . ABLE TO CARRY ?�';����//���q���^�~z|��ώQ�|�`���O���׻O����r����KG� n�{?�������G���̎�����>$�i���m�^f���,\:\g��i^��u �γ���iZ����E|V�M�Ħ�;�.��i|]��"������ƴ��E|Z��"~�;].���Ӎ��"^�m ���u�&Z��">-�e���ӭ< }��!�E�.��^����Vhϋ����E��w�?K׷L��E�.��>w}K���"��i/������+}��'�E�.���}���"��i/���oyo����F���{�3��XW&������q��w���D�y He says it’s too soon to return to work, raises his voice during occupational therapy sessions and accuses Kendra of siding with his employer. Summary of Recommendations. If a client chooses to end occupational services abruptly, OTs, if given the opportunity, should discuss the risks involved with that decision and provide suggestions for alternative or follow-up care. There has been some confusion that the OTA or COTA can write the discharge and just have the OT or OTR sign. Patient Telephone Number 6. Unique Identification Number 4. Rafael states that he prefers to close his file and be discharged from occupational therapy services. Discharge summary/Recommendations. from knee height to 30" height. Only an OT or OTR has the authority to discharge patients from occupational therapy services. (Category - Role of the OTA) 3. Makes necessary referrals to other professionals or facilities. Rafael disagrees with Kendra’s professional opinion. Assists in teaching patients and in planning discharge from occupational therapy services; COTA Supervision. Participates in operational and clinical functions for the department, hospital and corporation. ABLE TO LIFT. Rafael receives the letter and contacts the clinic to inform Kendra he is not ready to return to work and is seeking legal advice to explore his options. Patient/family Instructions (as appropriate) occupational therapy discharge summary BACKGROUND INFORMATION Date of report: April 23, 2016 Clients name: Date of birth &/or age: 53yo Date of referral: Jan. 25, 2016 Primary Intervention diagnosis/concerns: Left CVA Secondary diagnosis/concern: Expressive Aphasia Precautions/contraindications: N/A Reason for referral to OT: Symptoms of CVA are affecting … She attempts to contact him by phone on multiple occasions and is not successful. The discharge summary is required for each episode of outpatient therapy treatment. Rehabilitation Discharge Summary Medical Transcription Sample Report #2. (Category - Role of the OTA) 2. Please note: once the Lock button has been selected, the form will no longer be editable. Discharge Summary ... 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