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