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Welcome to Defensive Documentation for

Daily Treatment Notes

 

Course Author

Michelle Eliason

MS, OTR/L, CDS, CKTS, CBIS

Tone Management
Psychosocial and Behavioral Plan of Care
Comprehensive (whole body) Neurological Rehabilitation
Cognitive remedial therapy and dual tasking

Hello course user! 

Welcome to Defensive Documentation for Daily Treatment Notes. In this course, you will continue learning how to leverage the OTPF-4 to create documentation that  is supported by the OT domain and process. 

One thing I am passionate about is defensive documentation, and daily treatment notes are one of the major requirements for any OTP working in the medical sector. If OTPs want to be respected for their knowledge of both the medical and social approaches of healthcare, our documentation needs to lead the way!

Have fun in the course and I hope you learn something new from my perspective! 

– Michelle

 

Table of Contents (What to Expect)

Table of Contents
  1. Introduction to OT Clinical Process Documentation
  2. Introduction to “Intervention Phase”
  3. Constructing a daily treatment note with OTPF-4 language
  4. Components of a daily treatment note
  5. Examples

General Course Information

Course Objectives

Develop and enhance understanding of daily treatment and intervention documentation and rationale

Define and understand the concept of defensive documentation and what is included in documenting defensively.

How long will you have access to this course?

You will have access to this course for 1 year from the date you purchase it or for as long as you have a Thrive membership. Please note that this will depend on the purchasing option chosen.

How will your understanding be assessed?

Post completion of this timed-required course, you will be required to complete a short assessment of 5 questions including true/false, multiple choice, and matching that will determine your understanding of course materials. You will then complete a mandatory course review.

Do you require accommodations?

If you require accomodations for course access, please contact [email protected]. Thank you! 

Please download the following PDF

Defensive Documentation in Daily Treatment Notes: 

Full Link Below:

https://www.buffalooccupationaltherapy.com/wp-content/uploads/2022/08/Defensive-Documentation-in-Daily-Treatment-Notes.pdf