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Defensive Documentation BOT Portal - Buffalo Occupational Therapy

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Therapeutic Activity SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Neuromuscular Re Education SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Therapeutic Exercises SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Self Care and Occupation Specific SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Miscellaneous Patient Education SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Psychosocial and Behavioral SOAP Notes 1 - Buffalo Occupational Therapy

Tip: Press either “Ctrl + F” or “Command+F” on your keyboard and search for a keyword related to your intervention. You will then be able to copy and paste the caption.

Documentation - Buffalo Occupational Therapy

Tips for Defensive Documentation

Use language from the OTPF-4

State rationale and skill as an analyst

State how it relates to your scope of practice

Be thorough and leave no room for interpretation 

Write so that nobody can  can question your value and competence

Write so nobody can question medical necessity and justification of services the first time. 

How to Build Treatment Documentation

with Language from the OT Domain

Building OT Treatment Rationale - Buffalo Occupational Therapy

Therapeutic Activity Rationales

Billed as 97530

Balloon Toss - Buffalo Occupational Therapy

Balloon Toss

Balloon Toss
Beads and Spoons - Buffalo Occupational Therapy

Beads and Spoons

Beads and Spoons
Lacing Beads on Strong - Buffalo Occupational Therapy

Lacing Beads on Strong

Lacing Beads on Strong
Handwriting - Buffalo Occupational Therapy

Handwriting

Handwriting
Reading word flashcards - Buffalo Occupational Therapy

Reading word flashcards

Reading word flashcards
Keyboard Typing - Buffalo Occupational Therapy

Keyboard Typing

Keyboard Typing
Retelling and Narrating Past Events for Memory Enhancement - Buffalo Occupational Therapy

Retelling and Narrating Past Events for Memory Enhancement

Retelling and Narrating Past Events for Memory Enhancement
Visual Perception Worksheets - Buffalo Occupational Therapy

Visual Perception Worksheets

Visual Perception Worksheets

Therapeutic Exercise Rationales

Billed as 97110

Baoding Balls Treatment Rational - Buffalo Occupational Therapy

Baoding Balls Treatment Rational

Baoding Balls Treatment Rational
Arm Bike Treatment Rational - Buffalo Occupational Therapy

Arm Bike Treatment Rational

Arm Bike Treatment Rational

Self-Care and Community Management Rationales

Billed as 97535

Energy Conservation Treatment Rational - Buffalo Occupational Therapy

Energy Conservation Treatment Rational

Energy Conservation Treatment Rational

Adaptive Technology and Modification Education - Buffalo Occupational Therapy

Adaptive Technology and Modification Education

Adaptive Technology and Modification Education
Button Hook Training 1 - Buffalo Occupational Therapy

Button Hook Training 1

Button Hook Training 1

Neuromuscular Re-Education Rationales

Billed as 97112

Agility Ladder Treatment Rational - Buffalo Occupational Therapy

Agility Ladder Treatment Rational

Agility Ladder Treatment Rational

Static Stand and Reaching - Buffalo Occupational Therapy

Static Stand and Reaching

Static Stand and Reaching
Backward Walking 1 - Buffalo Occupational Therapy

Backward Walking 1

Backward Walking 1
Overhead Reaching Activity - Buffalo Occupational Therapy

Overhead Reaching Activity

Overhead Reaching Activity
Externally Supported Digit Isolation Grasp 1 - Buffalo Occupational Therapy

Externally Supported Digit Isolation Grasp 1

Externally Supported Digit Isolation Grasp 1
Wall Clock Multi Modal Activity - Buffalo Occupational Therapy

Wall Clock Multi Modal Activity

Wall Clock Multi Modal Activity
Cross Crawls - Buffalo Occupational Therapy

Cross Crawls

Cross Crawls

Supporting Interventions

Billed under main intervention code based on primary purpose

Cold Therapy 1 - Buffalo Occupational Therapy

Cold Therapy 1

Cold Therapy 1

Psychosocial and Behavioral Rationales

Billed under main intervention code based on primary purpose

Self Advocacy of symptoms and self reflection - Buffalo Occupational Therapy

Self Advocacy of symptoms and self reflection

Self Advocacy of symptoms and self reflection
Cognitive Distortions - Buffalo Occupational Therapy

Cognitive Distortions

Cognitive Distortions
Mind Mapping - Buffalo Occupational Therapy

Mind Mapping

Mind Mapping
Color Picture for Self Expression and Explain - Buffalo Occupational Therapy

Color Picture for Self Expression and Explain

Color Picture for Self Expression and Explain
Personality Assessment and Discussion - Buffalo Occupational Therapy

Personality Assessment and Discussion

Personality Assessment and Discussion
Time Line Intervention - Buffalo Occupational Therapy

Time Line Intervention

Time Line Intervention
Emotional Inventory - Buffalo Occupational Therapy

Emotional Inventory

Emotional Inventory