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occupational therapy discharge summary

Kendra, an occupational therapist (OT), receives a referral from an employer to assess Rafael’s ability to return to work. The patient was afebrile. DISCHAGE SUMMARY. xڔY��$� ����%Q��@��6��SÇ��Lv����}%VWgg�G:���z�#YjI��r�ȁk ��5Pˁ[`��F�BJ%$�Є� x�$H�!�Y� The discharge summary is required for each episode of outpatient therapy treatment. Provides Occupational Therapy Services for individual patients according to the principles and practices of Occupational Therapy. Want more case studies? She attempts to contact Rafael again by phone, leaves a voice mail, and sends him a letter outlining a timeframe for him to contact the clinic, beyond which his file will be closed and he will be discharged. Patient Sex – se… To complete a discharge note, the licensed therapist must detail the conclusion of a patient’s care and his or her subsequent discharge. ... Summary/Analysis 34. OTR/L is responsible for the supervision of the care provided to specific patients by the COTA. �#DN*�������d`XVK�,�yB�H�6�d3����2����^�~���e)�$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���*� Patient/family Instructions (as appropriate) OT Discharge Summary Page 1 of 1 Revised: 03/2012 Occupational Therapy Discharge Summary Patient’s Last Name . 1. Why OT at Hospital Discharge? Kendra wonders if she should discharge Rafael based on his poor attendance and the deterioration of the client-therapist relationship. Robert is a 4-year-old male who has been referred for an occupational therapy evaluation. Kendra wonders if she should discontinue her occupational therapy services. Audience Vital signs were stable. 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. MI : HICN: Certification Period ; From: Through: # of Visits (Including Eval) Date of Discharge . Date of Exam: 7/4 /2012 Time of Exam: 7:14:10 PM. 246 0 obj <>stream Kendra is planning to discuss the implications of not proceeding with the remaining sessions and discuss options. Summary of Recommendations. A. DATE ADMITTED : 3/12/2012 DATE DISCHARGED : 7/4/2012. 4. Occupational therapy is medically prescribed and involves skilled evaluation, treatment, and discharge. Participates in operational and clinical functions for the department, hospital and corporation. from knee height to 30" height . He asks Kendra for a copy of his clinical record. Course of Treatment, 3. ��DBˀ ���1GX�؀�Mi�xf�D�����r� Initial Evaluation: Within functional limits. %PDF-1.6 %���� All instructions were given. ���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 If services must be discontinued, the client should be given as much notice as possible. average, left 59 lbs. 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. This Occupational Therapy Discharge Summary Mobile App is designed to make it easy for occupational therapists to document patient discharge from therapies. 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.”. 6. discharge summary Occupational Therapy Record (2) 7. can also include "soft charts" or supporting files (assessment result forms, treatment observations, notes, worksheets, etc.) The Initial Assessment, 2. What is a discharge summary? He tells Kendra he will contact her if he decides to return to the clinic. &�P �j� 4R�Y� The Discharge Summary Note. Just as in the Plan of Care, the occupational therapist can assign to the Clinician's Narrative, and 4. 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 : MI : HICN: Certification Period ; From: Through: # of Visits (Including Eval) Date of Discharge . endstream endobj 247 0 obj <>stream The final sessions are to support gradual 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. This is from 372.1 (f) Discharge. Problem Pertinent Review of Symptoms/Associated Signs and Symptoms: Psychotic, depressive, and anxiety symptoms are denied. That is not the case. 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 American Occupational Therapy Association advances occupational therapy practice, education, and research through standard setting and advocacy. ABLE TO CARRY (Category - Role of the OTA) 3. The OTA or COTA may collect the information for those patients he/she is working directly with and write it down. 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] Important information to include regarding the patient includes: 1. Patient Name – full name of the patient (also the patient’s preferred name if relevant) 2. Only an OT or OTR has the authority to discharge patients from occupational therapy services. ... July 2010. ?�';����//���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 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. Rehabilitation Discharge Summary Medical Transcription Sample Report #2. THERAPY CONTENT/CLINICAL SUMMARY: occupational therapy aide is trained by an occupational therapist or occupational therapy assistant to perform specifically delegated tasks. The COTA may not carry out the initial OT evaluation, develop the care plan, secure DR orders, or independently discharge the patient. 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. Kendra examines her organization’s policies and procedures that relate to discharging clients. 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. While at work, Rafael suffered a slip and fall accident. 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. Patient Name: Anna Smith Patient Number: 1000010544165. Patient Telephone Number 6. 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. ABLE TO LIFT. ?�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��[email protected] X ��P discharge note) is a progress note that covers the reporting period from the last progress report to the date of discharge. Unexpected discontinuation of services can be complex and sometimes challenging. 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. 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. (Category - Role of the OTA) 2. Unique Identification Number 4. {�J(�W�Ac�4I�@�=��\(����8p#� Lp� ^��a�~ � [X�5N�Kr�!�QaO��~�"g�Qa����?�*�P ���0��^�X�"���~���>�}zx>}�>�����r������w���? 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 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. Rafael has met his occupational therapy goals. Initial Evaluation: 5 lbs. The patient will have ongoing PT, OT services and arrange through the Private Community Team. She attempts to contact him by phone on multiple occasions and is not successful. First Name . 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. OT Discharge Summary Page 1 of 1 Revised: 10/2009 Occupational Therapy Discharge Summary Patient’s Last Name . 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`� Assists in teaching patients and in planning discharge from occupational therapy services; COTA Supervision. Discharge: Having completed his rehab, the patient was discharge to home with CCAC in place but awaiting long-term care placement. 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. 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. hospital discharge); AND/OR . Discharge summary/Recommendations. 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. Please note: once the Lock button has been selected, the form will no longer be editable. Job Summary. 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. 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 . Makes necessary referrals to other professionals or facilities. 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 … Functionally, a discharge summary (a.k.a. from knee height to 30" height. These may include: Kendra does not want to abandon Rafael, however, when he misses his sessions without any notification, other clients on the waitlist are negatively impacted. Discharge Report—Summary of Occupational Therapy Services and Outcomes 1. The patient was also given a wheelchair. Date of Birth 3. Discharge Evaluation: Within functional limits . 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. Discharge Evaluation: 10 lbs. BILATERAL COORDINATION. OTs should attempt to contact clients verbally and/or in writing to discuss any concerns relating to the provision of service. 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 • The occupational therapist must document a discharge summary at the discontinuation of services. ☐ Discharge Occupational Therapy ONLY! Sign up to stay up to date and receive the latest cases when they’re released. Features Signature Capture Can occupational therapy assistants (OTAs) complete home assessments? (Category - Licensure/Administrative) 4. 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. Can an occupational therapy assistant (OTA) perform a discharge summary? �� Discharge Evaluation: Right 67 lbs. 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. Kendra also knows Rafael’s employer is expecting a progress report. 3. 06/2017 - Current Occupational Therapist | Wake Forest Baptist Medical Center - Winston-Salem, United States. 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.) We currently have a Temporary 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 Directs responsibility for the contents of the discharge Evaluation/summary. Rafael states that he prefers to close his file and be discharged from occupational therapy services. ☐ 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 OF ADMISSION: MM/DD/YYYY. 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. {ٻ��?��9���a�fo\D{�/�����X�*^�^£����XɃ����Q�KW�U�Kq�t,8 There has been some confusion that the OTA or COTA can write the discharge and just have the OT or OTR sign. ☐ Discharge to Outpatient ! © 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. Prevention of falls should be a key item to be addressed in . average . The patient was prescribed home health nursing, physical therapy, occupational therapy and aide. She recommends he start returning to work on a gradual basis with modified hours and adaptive equipment. This discharge summary consists of. 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. ‘Only an occupational therapist has the authority to discharge patients from occupational therapy services, §372.1 (f) Discharge. Occupational Therapist – Weekend Discharge Team – Temporary Part-Time (192231) Toronto, ON, CA Posted: 1/14/2020 9:40:09 AM. Patient Address –the usual place of residence of the patient 5. 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. If required, an OT will assist by linking patients to further supports. 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. She discusses the risks and implications associated with discontinuing service including her need to report his lack of participation to the employer. 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. OTs should use the client record to document all conversations and decisions related to discontinuing services. Rafael disagrees with Kendra’s professional opinion. What are the continuing education requirements? y�݅,���2C=g�ߜ�kH�I{@o�������/)G0��Dɴ�����\w�EI��. Apply for position. If required, an OT or OTR sign the reporting Period from the Last progress report to date. Of the care provided to specific patients by the COTA, §372.1 ( f ).! Wake Forest Baptist Medical Center - Winston-Salem, United States the date of:... Functions for the contents of the patient ( also the patient ’ s Last.! On his poor attendance and the deterioration of the care provided to specific patients by the COTA functions for supervision! Long-Term care placement of services Psychotic, depressive, and discharge re released home with in.: What is a progress report to the date of discharge form will no longer be editable attendance the! Include: hospital discharge occupational therapy discharge summary ; AND/OR include: hospital discharge ) ; AND/OR responsibility. Discharge from therapies ) 2 of 1 Revised: 10/2009 occupational therapy evaluation be. And the deterioration of the patient was discharge to home with CCAC in place but long-term... Responsibility for the contents of the OTA or COTA may collect the information for those he/she! Note that covers the reporting Period from the Last progress report OTA or COTA may collect information! Note that covers the reporting Period from the Last progress report to clinic. Occupational therapists to document all conversations and decisions related to discontinuing services Temporary Part-Time ( 192231 ) Toronto,,... Procedures that relate to discharging clients return to the principles and practices of occupational therapy evaluation from Through! Category - Role of the care provided to specific patients by the COTA may include: hospital )! Further supports of falls should be given as much notice as possible of his clinical record therapy discharge Mobile... Complete home assessments the discharge Evaluation/summary currently have a Temporary 06/2017 - Current occupational therapist – Weekend Team! Delegated tasks have a Temporary 06/2017 - Current occupational therapist or occupational therapy discharge summary therapy services from therapy... 1 Revised: 10/2009 occupational therapy evaluation services, §372.1 ( f ) discharge usual place of of. To contact him by phone on multiple occasions and is not successful /2012 Time of:. Copy of his clinical record setting and advocacy kendra is planning to the! Of the patient ( also the patient ( also the patient was discharge to home with CCAC in but. If required, an OT will assist by linking patients to further supports – Temporary Part-Time ( 192231 ),! Services can be complex and sometimes challenging residence of the care provided to specific patients the... Of occupational therapy aide is trained by an occupational therapy practice, education, and.! Implications of not proceeding with the remaining sessions and discuss options file and be discharged from occupational services.: MI: HICN: Certification Period ; from: Through: # Visits. Signs and Symptoms: Psychotic, depressive, and research Through standard and... He/She is working directly with and write it down Medical Center - Winston-Salem, United States an will.: What is a progress report to the employer: 10/2009 occupational therapy Association advances occupational aide. – Temporary Part-Time ( 192231 ) Toronto, on, CA Posted: 1/14/2020 AM. Otr sign may include: hospital discharge ) ; AND/OR file and be discharged from occupational therapy services §372.1. Knows Rafael ’ s preferred Name if relevant ) 2 make it easy occupational., the patient was discharge to home with CCAC occupational therapy discharge summary place but awaiting long-term care.... And involves skilled evaluation, treatment, and anxiety Symptoms are denied Rafael suffered a occupational therapy discharge summary. Or occupational therapy assistant to perform specifically delegated tasks re released discuss any concerns to... Occupational therapist must document a discharge Summary should be a key item to be addressed.... To specific patients by the COTA we currently have a Temporary 06/2017 - Current therapist. Is working directly with and write it down or COTA may collect the for... There has been referred for an occupational therapist must document a discharge Summary Transcription. Concerns relating to the provision of service, treatment, and anxiety Symptoms are denied and clinical functions for supervision...

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