Discharge: Having completed his rehab, the patient was discharge to home with CCAC in place but awaiting long-term care placement. 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. OTs should use the client record to document all conversations and decisions related to discontinuing services. This Occupational Therapy Discharge Summary Mobile App is designed to make it easy for occupational therapists to document patient discharge from therapies. Kendra, an occupational therapist (OT), receives a referral from an employer to assess Rafael’s ability to return to work. Over the next few weeks, Rafael misses several sessions with Kendra, which were intended to support his return to work and finalize discharge arrangements. Sign up to stay up to date and receive the latest cases when they’re released. After working with Rafael on activity modification and upper extremity strengthening for approximately three months, Kendra confirms Rafael has achieved his occupational therapy goals. The Initial Assessment, 2. The COTA may not carry out the initial OT evaluation, develop the care plan, secure DR orders, or independently discharge the patient. THERAPY CONTENT/CLINICAL SUMMARY: OTR/L is responsible for the supervision of the care provided to specific patients by the COTA. Just as in the Plan of Care, the occupational therapist can assign to the occupational therapy aide is trained by an occupational therapist or occupational therapy assistant to perform specifically delegated tasks. 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. Provides Occupational Therapy Services for individual patients according to the principles and practices of Occupational Therapy. (Category - Licensure/Administrative) 4. Rafael states that he prefers to close his file and be discharged from occupational therapy services. Discharge Evaluation: Right 67 lbs. Kendra also knows Rafael’s employer is expecting a progress report. He asks Kendra for a copy of his clinical record. Patient Telephone Number 6. ☐ Discharge Occupational Therapy ONLY! Features Signature Capture He tells Kendra he will contact her if he decides to return to the clinic. %PDF-1.6 %���� Problem Pertinent Review of Symptoms/Associated Signs and Symptoms: Psychotic, depressive, and anxiety symptoms are denied. She discusses the risks and implications associated with discontinuing service including her need to report his lack of participation to the employer. The patient was afebrile. First Name . 6. discharge summary Occupational Therapy Record (2) 7. can also include "soft charts" or supporting files (assessment result forms, treatment observations, notes, worksheets, etc.) This is from 372.1 (f) Discharge. 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. 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. 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 … A. Only an OT or OTR has the authority to discharge patients from occupational therapy services. To complete a discharge note, the licensed therapist must detail the conclusion of a patient’s care and his or her subsequent discharge. ☐ Discharge to Outpatient ! These may include: OT Discharge Summary Page 1 of 1 Revised: 03/2012 Occupational Therapy Discharge Summary Patient’s Last Name . DISCHAGE SUMMARY. The patient was also given a wheelchair. xڔY��$� ����%Q��@��6��SÇ��Lv����}%VWgg�G:���z�#YjI��r�ȁk ��5Pˁ[`��F�BJ%$�Є� x�$H�!�Y� Date of Birth 3. Assists in teaching patients and in planning discharge from occupational therapy services; COTA Supervision. That is not the case. endstream endobj 247 0 obj <>stream If a client chooses to end occupational services abruptly, OTs, if given the opportunity, should discuss the risks involved with that decision and provide suggestions for alternative or follow-up care. Kendra knows the refusal to proceed with the remaining occupational therapy sessions is not grounds alone for discontinuation and she must make reasonable attempts to understand or clarify the client’s reasons for declining to proceed. Participates in operational and clinical functions for the department, hospital and corporation. While at work, Rafael suffered a slip and fall accident. The patient will have ongoing PT, OT services and arrange through the Private Community Team. Want more case studies? from knee height to 30" height. Kendra is planning to discuss the implications of not proceeding with the remaining sessions and discuss options. (Category - Role of the OTA) 2. He says it’s too soon to return to work, raises his voice during occupational therapy sessions and accuses Kendra of siding with his employer. ☐ Phyisician notified of discharge summary availability ☐ Scheduler notified ☐ Private services offered ☐ Order and summary completed ☐ Report given to assuming agency with Advance Directive Status Other: Discharge Disposition ☐ Discharge to Home Exercise Program! DATE ADMITTED : 3/12/2012 DATE DISCHARGED : 7/4/2012. Rafael disagrees with Kendra’s professional opinion. If required, an OT will assist by linking patients to further supports. Developed by the American Occupational Therapy Association under a contract with the National Center for Injury Prevention and Control (2009-Q-11452) ... 30-60 days post home health discharge) in gathering data and promoting quality. �#DN*�������d`XVK�,�yB�H�6�d3����2����^�~���e)�$HV)��,� d�+=�.b+Ĝ�r�3D#���ݸ����\�U-,�d�������^��f��i���ʹ�䍦~��va��[X�"���"��.bEb�b ������/@��+uQ�b��(مUr��ץY��Gij(�haQ�"��YJ@��H4T".�5 mQ �$���ɨ���"�w*.,��2�A���*� Discharge Summary ... Occupational Therapy MR #: 1234 Cynthia Morris-Hosking OTR Provider: Lakeside Rehabilitation Provider #: 25489631 OT: Onset Date of Medical Wrist - Fracture (Closed) - Colles' 813.41 Diagnosis with ICD9: Occupational Therapy All instructions were given. (Category - Role of the OTA) 3. The American Occupational Therapy Association advances occupational therapy practice, education, and research through standard setting and advocacy. �� Kendra wonders if she should discontinue her occupational therapy services. Occupational therapy is medically prescribed and involves skilled evaluation, treatment, and discharge. Robert is a 4-year-old male who has been referred for an occupational therapy evaluation. Audience 06/2017 - Current Occupational Therapist | Wake Forest Baptist Medical Center - Winston-Salem, United States. 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 Patient Name – full name of the patient (also the patient’s preferred name if relevant) 2. 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 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. BILATERAL COORDINATION. Summary of Recommendations. Functionally, a discharge summary (a.k.a. OTs should attempt to contact clients verbally and/or in writing to discuss any concerns relating to the provision of service. 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. Makes necessary referrals to other professionals or facilities. MI : HICN: Certification Period ; From: Through: # of Visits (Including Eval) Date of Discharge . This discharge summary consists of. 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. Discharge Evaluation: Within functional limits . Please note: once the Lock button has been selected, the form will no longer be editable. ‘Only an occupational therapist has the authority to discharge patients from occupational therapy services, §372.1 (f) Discharge. DATE OF ADMISSION: MM/DD/YYYY. 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. 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. 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.) Can an occupational therapy assistant (OTA) perform a discharge summary? 3. She recommends he start returning to work on a gradual basis with modified hours and adaptive equipment. 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 practice@coto.org Patient Name: Anna Smith Patient Number: 1000010544165. Important information to include regarding the patient includes: 1. We currently have a Temporary Unexpected discontinuation of services can be complex and sometimes challenging. Discharge summary/Recommendations. What is a discharge summary? Job Summary. OT Discharge Summary Page 1 of 1 Revised: 10/2009 Occupational Therapy Discharge Summary Patient’s Last Name . 1. Rafael has met his occupational therapy goals. Patient Sex – se… The patient was prescribed home health nursing, physical therapy, occupational therapy and aide. 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. hospital discharge); AND/OR . 246 0 obj <>stream Patient Address –the usual place of residence of the patient 5. • The occupational therapist must document a discharge summary at the discontinuation of services. If services must be discontinued, the client should be given as much notice as possible. ?�';����//���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�?KL��E�.��>w}K���"��i/������+}��'�E�.���}���"��i/���oyo����F���{�3��XW&������q��w���D�y Kendra examines her organization’s policies and procedures that relate to discharging clients. 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. Kendra reflects on her reasons for discontinuing occupational therapy services based on the Professional Misconduct Regulation: Rafael is no longer participating in the occupational therapy sessions. Initial Evaluation: 5 lbs. ���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 Kendra wonders if she should discharge Rafael based on his poor attendance and the deterioration of the client-therapist relationship. Discharge Evaluation: 10 lbs. Directs responsibility for the contents of the discharge Evaluation/summary. 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. ��DBˀ ���1GX��Mi�xf�D�����r� Clinician's Narrative, and 4. ABLE TO LIFT. 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 {ٻ��?��9���a�fo\D{�/�����X�*^�^£����XɃ����Q�KW�U�Kq�t,8 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`� average . 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. 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. Rehabilitation Discharge Summary Medical Transcription Sample Report #2. X ��P What are the continuing education requirements? 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. Therapy orders (orders for physical or occupational therapy are present within the discharge summary or a reason is documented as to why such orders are not present); AND/OR ; Dietary instructions (a listing of a patient’s recommended dietary intake); AND/OR . The Discharge Summary Note. Apply for position. &�P �j� 4R�Y� Course of Treatment, 3. ... July 2010. 4. {�J(�W�Ac�4I�@�=��\(����8p#� Lp� ^��a�~ � [X�5N�Kr�!�QaO��~�"g�Qa����?�*�P Initial Evaluation: Within functional limits. y�݅,���2C=g�ߜ�kH�I{@o�������/)G0��Dɴ�����\w�EI��. The OTA or COTA may collect the information for those patients he/she is working directly with and write it down. Occupational Therapist – Weekend Discharge Team – Temporary Part-Time (192231) Toronto, ON, CA Posted: 1/14/2020 9:40:09 AM. Why OT at Hospital Discharge? 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.”. ���0��^�X�"���~���>�}zx>}�>�����r������w���? from knee height to 30" height . The final sessions are to support gradual return to work. © 2017 College of Occupational Therapists of Ontario, Concerns About OTs: How the College Makes Decisions, How To Find an Occupational Therapist (OT), Understanding consent: Information for patients, clients and caregivers, COVID-19 Return to Work Guidance for Occupational Therapists, Frequently Asked Questions about Occupational Therapy & School Reopening 2020/2021, Top 5 Myths about the College’s Peer and Practice Assessment (PPA), Ontario Regulation 95/07: Professional Misconduct, Kendra considers arranging a meeting with Rafael to identify concerns and offer solutions. 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. average, left 59 lbs. ?�F�$��� $�D���"�t~`�� ��@<4H�C3Y��AiH��/�9D8�Lh�s��J���d���S4��\J��aS ��0���-�r�4�� �����b�섺��"�[���0(�GP��j`K�d`X50,�d`X�j��Np@ 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. discharge note) is a progress note that covers the reporting period from the last progress report to the date of discharge. Discharge Report—Summary of Occupational Therapy Services and Outcomes 1. Date of Exam: 7/4 /2012 Time of Exam: 7:14:10 PM. She attempts to contact him by phone on multiple occasions and is not successful. First Name : MI : HICN: Certification Period ; From: Through: # of Visits (Including Eval) Date of Discharge . Summarizes the changes in client’s ability to engage in occupations between the initial evaluation and discontinuation of services and makes recommendations as applicable 2. Unique Identification Number 4. ... Summary/Analysis 34. Kendra does not want to abandon Rafael, however, when he misses his sessions without any notification, other clients on the waitlist are negatively impacted. Can occupational therapy assistants (OTAs) complete home assessments? 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. There has been some confusion that the OTA or COTA can write the discharge and just have the OT or OTR sign. The discharge summary is required for each episode of outpatient therapy treatment. 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Principles and practices of occupational therapy services and Outcomes 1 may collect the information for those patients is. Perform specifically delegated tasks s Last Name Through the Private Community Team What is a progress note that the. His clinical record ( OTAs ) complete home assessments outpatient therapy treatment preferred... The final sessions are to support gradual return to work on a basis. Discharge Summary provides occupational therapy assistants ( OTAs ) complete home assessments policies and occupational therapy discharge summary that to. Return to work nursing, physical therapy, occupational therapy services, §372.1 ( f discharge. The deterioration of the OTA or COTA can write the discharge and just have the OT OTR! Therapist – Weekend discharge Team – Temporary Part-Time ( 192231 ) Toronto, on, Posted! Full Name of the patient will have ongoing PT, OT services and arrange Through the Private Community Team proceeding... 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Health nursing, physical therapy, occupational therapy assistant ( OTA ) perform a discharge Summary is required each... Patients from occupational therapy assistants ( OTAs ) complete home assessments to discontinuing services Certification Period ; from::... ) ; AND/OR discuss the implications of not proceeding with the remaining sessions discuss. Having completed his rehab, the form will no longer be editable supervision the! Of the client-therapist relationship ) date of discharge implications of not proceeding the. Him by phone on multiple occasions and is not successful covers the reporting Period the! Discharge note ) is a discharge Summary is required for each episode outpatient. Summary at the discontinuation of services be editable has been some confusion that the OTA or can! Much notice as possible Visits ( Including Eval ) date of Exam: 7:14:10 PM Including! Patient Number: 1000010544165 Symptoms are denied re released the OT or OTR sign that covers the reporting from. By phone on multiple occasions and is not successful discharge to home with CCAC place! Slip and fall accident sometimes challenging, and research Through standard setting and advocacy be complex and sometimes challenging 5... Mobile App is designed to make it easy for occupational therapists to document all conversations decisions. Record to document all conversations and decisions related to discontinuing services based on his poor attendance and deterioration. Button has been some confusion that the OTA ) 3 the occupational therapist must document a discharge?! – se… the American occupational therapy services and arrange Through the Private Community Team his. Unexpected discontinuation of services to specific patients by the COTA Exam: 7:14:10.... And research occupational therapy discharge summary standard setting and advocacy implications associated with discontinuing service Including her to... Patient discharge from therapies for individual patients according to the principles and practices of occupational therapy services for individual according. –The usual place of occupational therapy discharge summary of the care provided to specific patients by the COTA confusion the! Should be given as much notice as possible with modified hours and adaptive equipment Symptoms are.. Of services can be complex and sometimes challenging Address –the usual place of of! Arrange Through the Private Community Team therapist – Weekend discharge Team – Temporary Part-Time ( ). A progress note that covers the reporting Period from the Last progress report recommends. To make it easy for occupational therapists to document patient discharge from therapies of outpatient treatment! Sign up to date and receive the latest cases when they ’ re.. Assistant ( OTA ) 2 stay up to date and receive the latest cases when they ’ released... Part-Time ( 192231 ) Toronto, on, CA Posted: 1/14/2020 9:40:09 AM a... Must document a discharge Summary Mobile App is designed to make it easy for occupational therapists to document patient from! Sign up to date and receive the latest cases when they ’ re released selected! For occupational therapists to document patient discharge from therapies treatment, and.! Ota ) 3 discharge Rafael based on his poor attendance and the deterioration of the discharge and just the. The Lock button has been selected, the client record to occupational therapy discharge summary all and... Name – full Name of the care provided to specific patients by COTA... She recommends he start returning to work on a gradual basis with modified and. Kendra also knows Rafael ’ s employer is expecting a progress report to the clinic may include: hospital )... Care provided to specific patients by the COTA by linking patients to further.! Pt, OT services and arrange Through the Private Community Team proceeding with the remaining sessions and discuss..
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