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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
Therapeutic Activity Rationales
Billed as 97530
Balloon Toss
The patient engaged in a remediation-based activity using repetition catch-release of inflated balloon to enhance participation in ADL (Showering with reaction time to move when something is falling). The patient sat unsupported at edge of seat using alternating BUE to improve postural control, core stability, righting reaction, as well as alignment, calibration, flow, and endurance related to upper extremity performance. The patient performed 5x10 each arm in multiple planes without c/o fatigue or pain.
Beads and Spoons
The patient engaged in a training activity using a spoon with visual target in trough and multi-colored beads to remediate performance in ADL (self-feeding to decrease dropping food on shirt). The patient sat with trunk supported posteriorly and laterally to improve focus on fine motor accuracy while addressing deficits of proprioception and control of voluntary movement. Specific skills related to LUE and trunk structures include positioning, alignment, stabilizaion, in order to reach, calibrate, grip, manipulate fine motor tools. The patient retrieved 1 bead and placed in corresponding receptical (6 recepticals in multiple planes and elevations) x15 reps. >10 VCs necessary for spoon orientation, prehension, and body mechanics.
Lacing Beads on String
The patient engaged in a remedial activity using a string and multi-colored beads to improve performance in Work (Seamstress specializing in buttonwork). The patient sat at EOT with BUE elbows supported proximally and beads, string, and scissors setup within arms-length reach. The activity improves performance skills related to BUE including initiation of task, reach, in-hand manipulation, and handling small objects with right hand while simultaneously stabilizing object with left hand (BUE coordination). Activity enhances pacing and mm endurance along with voluntary movement control. The patient successfully beaded 20/20 beads with 18 errors (dropping beads) in 18m23s. Patient states, "I am motivated to improve my performance in this."
Handwriting
The patient engaged in a habilitative activity to improve handwriting on large-lined paper to establish and enhance performance in Education (beginning to take notes in class). The patient sat in chair with proper body mechanics at shoulder, pelvis, hips, knees, and ankles with paper at appropriate orientation to patient. Therapist provided hand over hand support for 25% of task and patient used adaptive external utensil support. The activity targets/seeks to improve attention, perception, and temperament regulation as well as RUE performance skills including the ability to stabilize writing utensil, position self in proper alignment and effectively utilize eye-hand coordination, The patient successfully wrote the alphabet (26 characters) within boundaries with 100% accuracy. Total completion time 22m14s.
Reading word flashcards
The patient engaged in a remedial activity of visual perception and word identification using 20 relevant vocabulary words to enhance performance in leisure and medication management occupation (reading newspaper and prescription captions). The patient was sitting unsupported at table and required to read 20/20 large print words within 20 minutes. Body functions being utilized and addressed include visual functions with information processing speed, perception, attention, and mental function. Performance skills of the eyes and neuromusculoskeletal system addressed including the ability to attend to and endure the length of the activity. The patient completed 20/20 words (10 required VC, 10 done independently) within 18m15.
Keyboard Typing
The patient engaged in remedial activity of word identification and keyboard typing to enhance performance in social participation, health management, and leisure previously enjoyed with PLOF (the patient types e-mails to communicate with family, types for medical portal, uses typing skills for computer-based past-time). The patient sat supported with proper body mechanics to perform tabletop typing activity with modified keyboard to enhance visual attention to alpha characters. 13 large print words were reviewed and spelled aloud by patient prior to commencement. Activity targets deficits in visual perception, sustained attention, mental function, and voluntary motor control while improving neuromusculoskeletal performance skills of fine motor coordination, precision, endurance, mm calibration for refine movement, and movement flow when performing kinematic synergies of bilateral hands. The patient demonstrated maximum difficulty the activity to be graded down and chunked into letter by letter relay for each word due to attention span of less than 30 seconds during cognitive-motor dual task. 4/13 words complete in 28m13s. Patient remained focused and engaged.
Retelling and Narrating Past Events for Memory Enhancement
The patient engaged in a cognitive remedial activity requiring mental imagery and reflection to sequence yesterday's events with detail in order to improve quality of engagement in social participation, ADL, IADL, and Leisure (executive function, attention and memory, required to effectively communicate within these occupational categories). The patient sat comfortable and support in a minimally stimulating environment with instruction to close bilateral eyes in order to envision, mentally sequence, organize, and communicate events from previous day. This activity supports and is noted to improve multiple functions within OT domain including high level cognition, mental functions of sequencing, attention, memory, experience of self and time, and orientation to time. Carer present to confirm patient inaccurately relayed details with corrections to 10/12 elements of told narrative demonstrating patient is a poor historian. The patient will be required to retell a scenario from start of session at end of session to assess temporal limits to short term memory.
Visual Perception Worksheets
The patient engaged in a therapeutic activity to remediate visual perception and executive function in order to improve reading, writing, and overall communication during ADLs, IADLs, Health Management, and Social Participation The patient was required to complete a series of clinical interventions on tabletop with close supervision and continuous skilled training to ensure maximum carryover during assigned HEP. Rational for each clinical tool is included following this note. Visual perception is often times linked with inattention which impacts executive function and results in distortion of sensory information required for effective visual motor integration during communication-based activities within various contexts. Occupational Therapy tools combine numerous components of visual perception that impact both visuomotor performance and memory/executive function including form constancy, sequencing, visual closure, visual memory, visual sequential memory, figure-ground, spatial relations, visual discrimination, and visual scanning/tracking. By addressing visual perception, the patient is able to attend and process incoming information with greater accuracy improving overall wellbeing. The patient performed as follows:
Therapeutic Exercise Rationales
Billed as 97110
Baoding Balls
The patient engaged in a remedial-based activity using 21 oz baoding balls to improve participation in IADL (meal prep). The patient sat supported with elbows supported proximally with instruction disallow structures to touch. Activity improves neuromuscular and motor control as well as manipulation, coordination, calibration, flow, pace, and endurance related to bilateral hand performance. The patient performed (1) 3-minute interval each hand with improvements noted based on an increase 10 revolutions in each trial.
Arm Bike
The patient engaged in a remedial-based activity using upper body exerciser to support and improve participation in IADL and primary caregiver of infant twins. The patient stood unsupported with UBE at counter-level required to use BUE simultaneously. Activity improves joint mobility and stability, muscle power, tone, and endurance as well as BLE, BUE, Pelvic/Trunk-related skills including the ability to stabilize, align, and hold position during performance, reach, grip, coordinate, calibrate, and endure without pausing to rest. The patient performed 10 consecutive minutes of task using proper weight shift without c/o of fatigue demonstrating improvement since last session.
Self-Care and Community Management Rationales
Billed as 97535
Energy Conservation
The patient engaged in modification-based education and training of energy conservation techniques to support and improve participation in health management of chronic degenerative illness. The patient required minimal distractions and dereased visual stimuli during education. Education and training addressed strategies of joint stability and muscle endurance as well as skills related to neuromuscular structures including the ability to heed and choose strategies discussed and adjust and accomodate body mechanics for context. The patient was able to understand and discuss 5/5 energy conservation strategies which are assigned for weekly HEP.
Adaptive Technology and Modification Education
The patient engaged in an education and preliminary assistive tech/environmental modification-based discussion activity with husband present in order to establish modifications and minimize present disability during engagement in ADLs, IADLs, Leisure, and Social Participation as well as increase performance in health management (5/9 categories of occupation within scope of practice). The patient and husband provided discussion topics and therapist transcribed collaborative action steps to serve as visual support during implementation outside clinic. In consideration of degenerative motor-based condition affecting BUE, the activity facilitated patient self-reflection on concerns impacting pyschosocial , personality, and emotional health and well-being as well as energy and sleep functions. To ensure carry over, the patient was required organize thoughts, initiate organized feedback related to barriers, and acknowledge action-steps need to be made. 8 barriers acknowledged, 6 action steps given for HEP.
Button Hook Training
The patient engaged in an occupation-based activity for the purpose of training in a modified approach to the manipulation of fasteners using a button hook in order to enhance performance of ADL (buttoning pants and shirts). The activity was performed EOB unsupported requiring use of right affected UE to stabilize button hook and fasten small buttons using his own shirt for familiarity placed on tabletop in front of patient. The activity targeted fine motor mm endurance, control of voluntary movements, and touch functions in order to train attention, sequencing complex movements, fine motor coordination, digit opposition, pincer grasp, intrinsic muscle control, and eye-hand coordination. Cognitive behavioral techniques invoked to create habituation in adaptive equipment utilization. Buttoning 5/5 buttons using buttonhook took 6m32s and 5 verbal cues for motor planning.
Neuromuscular Re-Education Rationales
Billed as 97112
Agility Ladder
The patient engaged in a remedial-based activity using a high-contrast agility ladder to support and improve participation in ADL/IADL (functional mobility during dog-walking requiring agility and stability when dog pulls in every direction) . The patient required CGA AAT while ambulating through 10ft ladder. Activity improves joint stability, muscle endurance, and motor control as well as skills related BLE, pelvis, and trunk including the ability to coordinate, move, walk, and flow while initiating , sequencing, and terminating movement. The patient performed 5 reps (50ft) in a linear pattern which required him to alternate between a narrow BOS and wide BOS x6 step sequence. 4 errors in sequence without LOB.
Static Stand and Reaching
The patient engaged in remedial-based activity requiring repetitive opportunities to engage in static standing with alternating BUE reach in multiple directions in order to improve performance in ADL, IADL, and leisure (functional mobility required to walk to bathroom, bedroom, or kitchen, stand for greater than 2 minutes at sink, reach in cupboard). The patient performed static standing activity under supervision using unilateral UE support at parallel bar for support. Patient given tactile cues and education for proper body mechanics related to feet, ankles, knees, and hips while standing. The activity addressed deficits in joint stability, proprioception, m power, m tone, and m endurance while encouraging improved performance in BLE structures and trunk related to stabilization, alignment, and positioning of UE and LE when performing activity at counter level. The patient alternated UE reach in multiple planes to target with greater than 10 cues to improve posture. The patient performed 10 x 2m standing-reaching sets without LOB. Given 1m30 rest between each set to prevent exhaustion. Task achievable but difficult.
Backward Walking
The patient engaged in a remediation-based activity of backward walking to enhance participation in ADL safety (Stepping backward when opening doors and lower cupboards ). The patient was required to identify posterior target, shift gaze forward, and ambulate backwards 10ft to target with CGA at Pelvic KPC. Activity improves proprioception, movement control, joint stability, and perception as well as BLE, pelvis, and trunk-related skills of alignment, positioning, coordination, and the ability to move external structures with stability. The patient performed 5 reps (50ft) with 3 errors in judgment but without LOB.
Overhead Reaching Activity
The patient engaged in a remedial-based activity to improve overhead reach bilaterally and kinematic awareness of posture, pelvis, and BLE for the improvement of IADL (standing at the counter and putting cups away in overhead cupboard) and ADLs (lifting arms above head for dressing and showering). The patient was required to use a cylindrical grasp while holding a weightless bar while rhythmically tapping color-based targets placed at various elevations in a specified pattern. This activity required close supervision during standing and >10 verbal cues for body mechanics. The activity used to strength functions of mm strength, power, and endurance throughout BUE, trunk, pelvis, and BLE in order to maximize ability to align, stabilize, and sustain engagement during occupational performance. The patient performed 5 levels of elevation requiring between 90-160 degrees of shoulder flexion 9 sets of 8 with requirement to stand for 2m30s during each set prior to receiving 1m30s rest.
Externally Supported Digit Isolation & Grasp
The patient engaged in a remedial-based activity promoting kinematic synergies of the left hand using external support, AROM, and isometric contractions in order to enhance participation in Work (typing, writing utensil support) and leisure (exercise). The patient sat unsupported at tabletop with forearm supported. External support aide (coban) was used to secure the left hand to the task object using a in a cylindric grasp pattern. This activity targets muscle power, strength, and endurance through intrinsic and extrinsic mm of the left forearm/hand as well as voluntary control of DIP/PIP full join excursion in order to improve coordination and calibration during activity. The patient performed 3 sets of 3-second isometric holds in each digit of the LUE and offered rest in neutral post activity. No complaints offered, but reports feeling mm fatigue throughout digit.
Wall Clock Multi-Modal Activity
The patient engaged in a restorative/remedial activity for the improvement of performance in ADLs (functional mobility and ambulation required for all occupations including leisure and social participation). The patient was required to endure a multi-modal, dynamic standing activity with close supervision using a constructed wall clock layout with 4ft diameter. The patient was given command to tap a specific number between 1 and 12 located in multiple planes of movement while alternating use of BUE and shifting gaze between right and left, upper and lower quadrants. Activity targeted joint mobility, voluntary control of movement, and mm endurance as well as visual, hearing, and proprioceptive functions in order to improve ability to align and position self in space during functional task as well as the ability to reach and bend toward target while coordinating upper and lower extremities, calibrating movement, and performing all smoothly and fluidly. 40 targets per minute, 2 minute duration. The patient was noticeably fatigued and required 1m30s rest between sets. 8 sets total. Errors are to follow.
Cross Crawls
The patient engaged in restorative neuromuscular re-education activity required for improvement of upper and lower body dressing within the occupation of ADL and object retrieval during ambulation when shopping (IADL). The patient was required to demonstrate motor control during slow contralateral movements in frontal and sagittal planes of movement while standing with unilateral UE support in coordination with the external auditory cue of 50 bpm. Full excursion of multi-joint mobility and mm elongation promoted throughout the activity. The activity is supported to promote neural re-patterning, neural organization, enhancement of cognition, and interhemispheric communication to positively impact performance across the 9 categories of occupation. The patient performed 2 x 25 reps of each movement, bilaterally with CGA for safety. No LOB was noted, but the patient required one self-initiated rest break of 4 minutes between sets.
Supporting Interventions
Billed under main intervention code based on primary purpose
Psychosocial and Behavioral Rationales
Billed under main intervention code based on primary purpose
Self Advocacy of symptoms and self reflection
The patient engaged in education-based activity to teach and promote self-advocacy while reflecting on the impact that the exacerbation of primary diagnosis (PD) continues to have on his performance in ADLs, IADLs, leisure, health management and social participation. The patient was given time to process and reflect on current level of function with clinical guidance on how to communicate status to a third party. The patient requires continued practice in this and guidance by clinician due to diagnosed cognitive deficits and declining psychosocial skills. This activity targets and addresses deficits in higher level cognition, though, experience of self, and consciousness in order to improve the ability to attend to one topic in a conversation as well as start and terminate an appropriate reply that discloses appropriate information in an appropriate time duration. The patient able to expand from 1-2 word response to a full sentence with 3 verbal cues after 2m25s.
Cognitive Distortions
The patient engaged in educational activity that only a clinical professional trained in mental health, behavioral, and psychosocial concepts could direct regarding cognitive distortions and how they impact occupational performance in IADLs, Social Participation, Leisure, and Volunteering. The patient was required to reflect on 12/12 cognitive distortions and define characteristics that were similar and dissimilar to reality in order to improve function in consciousness, temperament and personality, psychosocial stability, and experience of self and time. Key performance skills of neurological systems/structures were targeted, encouraged, and improved including the ability to express emotion in a social appropriate manner, ask relevant questions, and the ability to disclose necessary information to ensure therapeutic growth and achievement of goals.The patient demonstrated understanding as evidenced by collaborative discussion on each concept.
Mind Mapping
The patient engaged in a therapeutic activity using mind/cognitive mapping and action-oriented steps as an external aide to establish executive skills necessary to improve engagement in IADL, Social Participation, and Leisure (Financial management, developing and maintaining appropriate relationships, and achieving balance between person-environment- occupation). The activity targeted and sought to improve and enforce higher level cognition and thought required to maximize goal achievement of the following performance skills addressed within the OT Scope of Practice: Sequencing logical order to avoid randomness or repetition of steps and effectively heeding education and training taught in previous sessions to choose the appropriate and most realistic outcomes for self. The patient was able to create (2) 4 step cognitive/action maps to process relationship-based performance barrier.
Color Picture for Self Expression and Explain
The patient engaged in a education, training, and self-advocacy-based activity using guided communication related to the the patient-fabricated artwork related to perception of self using meaningful colors for the purpose of enhancing social participation and work (role of carer, daughter, and friend, relationship with self, and ability to volunteer in preparation to return to the work force). The patient completed task in a minimally stimulating environment with printed image for visual guidance throughout communication. The activity targeted and enhanced functions required stated occupational performance deficits including perception, thought, emotional-behavioral processing, personality, and experiences of self within her current temporal context. Through clinically guided discussion, the patient was able to effectively shape content and maintain flow of social interaction while verbally supporting the conversation with relevant information. The patient identified 4/4 colors used, corresponding subjective meaning, and create helpful mind map to convert present cognitive distortions with realistic explanations to improve self-perception and increase internal locus of control. Introduction and explanation of beginning with psychotherapy to address past trauma influencing self-perception discussed with agreement.
Personality Assessment and Discussion
The patient engaged in a self-regulation-based restorative activity using a personality-based assessment partnered with guided clinical discussion in order to promote role competence in work and IADLs as it relates to her life transition and acclimation to being an independent autonomous adult. The patient sat undistracted in a minimally stimulating environment and attended to a reciprocal and interactive engagement. Activity targeted and addressed higher level cognitive functions, thought, perception, personality/temperament, and psychosocial functions required to perform social interaction skills of regulation, expression, accommodate for unexpected actions/occurrences of social requirements.Total sustained attention 42minutes with appropriate social transition and response.
Time Line Intervention
The patient engaged in a education/self-regulatory-based activity using a time line approach in order to improve new role acquisition within social participation and work occupations (development of new companion, creating new boundaries with current relationships, and volunteering). The activity chosen invoke introspection which allows the patient to surrender negative or inauspicious emotions linked to past experiences and begin to transform their internal programming and distinguish between images of the past and perceptions of the future. Internal programming is often the mechanism that is responsible for outward expressions of emotions which interferes with maximum occupational engagement and decreases internal locus of control. The activity today targeted health and well-being of Psychosocial function, perception, and temperament and personality in order to improve his ability to produce, physically support, and shape content for social interaction. 4 personal events discussed and comparison created for positive outcomes.
Emotional Inventory
The patient engaged in a self-regulation therapeutic activity to promote emotional stability in preparation for social participation (category of occupation) during leisure and familial roles. The patient must self-initiate introspection and enteroception during clinically guided reflection of relationships and events by choosing from 3-5 emotions from a comprehensive list of emotions. Subsequently, the patient must discuss both barriers and supports the emotion/perspective may have on current occupational performance. Effective emotion regulation and higher-level cognition (insight) involve the ability to accurately detect and evaluate cues related to physiological reactions to stressful events, accompanied by appropriate regulation strategies that temper and influence the emotional response. The patient productively discussed topics within 4/9 areas of wellness and well-being as noted below: