Study Notes/Occupational Therapy/Assessment & Documentation

Assessment & Documentation

Evaluation process, documentation standards, and professional ethics in OT

1. OT Evaluation Process 2. Types of Assessments 3. Standardized Assessments 4. Documentation Standards 5. SOAP Notes 6. Treatment Planning 7. Professional Ethics 8. Laws & Regulations

1. OT Evaluation Process

The OT evaluation determines what the client wants and needs to do, identifies factors that support or hinder occupational performance, and establishes goals and intervention priorities.

Two Components of Evaluation (OTPF)

1. Occupational Profile

Client-centered summary of occupational history and experiences

Why is client seeking services?
What occupations are important?
What contexts support/hinder performance?
What is the client's occupational history?
What are client's priorities and goals?

2. Analysis of Occupational Performance

Observe and measure performance in context

Observe performance in occupations
Identify performance skills used
Assess client factors
Identify supports and barriers
Develop intervention plan

Evaluation Methods

Method	Description	Examples
Interview	Gather subjective information from client/caregiver	COPM, OCAIRS, occupational history
Observation	Watch performance in natural or structured context	ADL observation, AMPS, ACIS
Standardized Testing	Formal assessments with established protocols	BOT-2, Beery VMI, FIM
Chart Review	Review medical records and history	Diagnosis, precautions, prior level
Self-Report	Questionnaires completed by client	OSA, Role Checklist, Interest Checklist

Top-Down vs Bottom-Up Approach

Top-Down (Preferred in OT)

Starts with occupations and roles
Client-centered focus
Identifies meaningful activities first
Then explores contributing factors
Occupation-based assessment

Bottom-Up

Starts with impairments
Focuses on components first
ROM, strength, sensation
Then addresses function
More medical model approach

2. Types of Assessments

Standardized vs Non-Standardized

Standardized

Established protocols and procedures
Normative data for comparison
Tested for reliability and validity
Consistent administration
Examples: FIM, BOT-2, Beery VMI

Non-Standardized

Flexible, informal assessment
No normative data
Clinical observation
Activity analysis during tasks
Examples: ADL observation, interviews

Psychometric Properties

Property	Definition	Types
Reliability	Consistency of measurement	Test-retest: consistency over time Inter-rater: consistency between raters Internal consistency: items measure same construct
Validity	Accuracy of measurement (measures what it claims)	Content: covers relevant content Criterion: correlates with gold standard Construct: measures theoretical concept
Sensitivity	Ability to detect change over time	Important for outcome measurement

Norm-Referenced vs Criterion-Referenced

Norm-Referenced

Compares to normative sample
Identifies where client falls in distribution
Standard scores, percentiles
Example: BOT-2, Beery VMI

Criterion-Referenced

Measures against set standard
Can or cannot perform task
Mastery-based
Example: FIM, ADL checklists

3. Common Standardized Assessments

Functional/ADL Assessments

Assessment	Population	Key Features
FIM	Adults (rehab)	18 items; 7-point scale; motor and cognitive domains
WeeFIM	6 months - 7 years	Pediatric version of FIM
Barthel Index	Adults	10 items; 0-100 scale; basic ADLs
COPM	All ages	Client-identified goals; rates importance, performance, satisfaction
AMPS	3+ years	Observation of motor and process skills during IADL tasks

FIM Scoring Scale

Independent

7 - Complete Independence: Timely, safely
6 - Modified Independence: Device, extra time, safety concern

Dependent

5 - Supervision/Setup: Cueing, coaxing, setup
4 - Minimal Assist: 75%+ effort by client
3 - Moderate Assist: 50-74% effort by client
2 - Maximal Assist: 25-49% effort by client
1 - Total Assist: <25% effort by client

Motor/Developmental Assessments

Assessment	Age Range	Measures
BOT-2	4-21 years	Fine motor precision, integration, dexterity; manual coordination; body coordination; strength/agility
PDMS-2	Birth-5 years	Reflexes, stationary, locomotion, grasping, VMI
Bayley-4	1-42 months	Cognitive, language, motor, social-emotional, adaptive
Beery VMI	2-100 years	Visual-motor integration; supplemental VP and MC tests

Sensory/Perception Assessments

Sensory Profile 2

Caregiver questionnaire
Infant, Toddler, Child, School Companion, Adult
Identifies sensory processing patterns
Based on Dunn's model

TVPS-4

Test of Visual Perceptual Skills
5-21 years
Motor-free visual perception
7 subtests: discrimination, memory, spatial, etc.

4. Documentation Standards

Types of Documentation

Type	Purpose	Content
Screening Report	Determine need for evaluation	Brief findings, recommendations
Evaluation Report	Document findings, establish plan	Background, assessments, goals, plan
Progress Note	Document ongoing treatment	Session content, response, progress
Re-evaluation	Reassess status, update plan	Current status, progress, revised goals
Discharge Summary	Document outcomes, recommendations	Progress summary, recommendations, referrals

Documentation Principles

Accurate: Factual, objective information
Complete: All relevant information included
Timely: Documented promptly after service
Legible: Clear and readable
Professional: Appropriate terminology, no abbreviations that could be misunderstood
Signed and dated: With credentials
Client-centered: Focus on function and occupation

Legal Considerations

Documentation is a legal record
Never falsify or backdate entries
Use single line through errors, date and initial corrections
Never use white-out or erasures
"If it wasn't documented, it wasn't done"
Maintain confidentiality (HIPAA in US)

5. SOAP Notes

SOAP is a structured format for progress notes that organizes information in a logical, consistent manner.

S - Subjective

What the client/caregiver reports

Client's statements (in quotes)
Reported symptoms, concerns
Pain level, mood
Caregiver observations

Example: Client stated, "My hand feels stronger today."

O - Objective

Measurable, observable data

Treatment provided
Performance observations
Assist levels, cues needed
Measurable data (ROM, time, reps)

Example: Client completed dressing with min A for buttons.

A - Assessment

Clinical interpretation and analysis

Progress toward goals
Factors affecting performance
Clinical reasoning
Response to treatment

Example: Client progressing toward dressing goal; improved fine motor coordination.

P - Plan

Next steps and recommendations

Frequency and duration of treatment
Focus of next session
Modifications to plan
Referrals or recommendations

Example: Continue OT 3x/week; progress to smaller buttons next session.

Tips for Writing SOAP Notes

Be specific: "Min A x2 verbal cues" not "some help"
Use measurable terms: Percentages, assist levels, time
Connect to goals: Show progress toward stated objectives
Justify services: Document skilled intervention
Focus on function: Relate to occupational performance

6. Treatment Planning

Writing Goals: SMART Format

S - Specific: Clear, detailed behavior
M - Measurable: Quantifiable criteria
A - Achievable: Realistic and attainable
R - Relevant: Related to client's priorities
T - Time-bound: Target date for achievement

Goal Components (ABCD Format)

A - Audience: Who (the client)
B - Behavior: What they will do (observable, measurable)
C - Condition: Under what circumstances
D - Degree: To what level/criteria

Example Goal

Client (A) will independently don a pullover shirt (B) while seated in wheelchair (C) in 3 out of 4 trials within 2 weeks (D).

Long-Term Goals (LTGs) vs Short-Term Goals (STGs)

Long-Term Goals

Achieved by discharge
Functional outcomes
Broader, overarching
Directly related to occupational performance

Short-Term Goals

Stepping stones to LTGs
Achieved in shorter timeframe
More specific, component-focused
Progress markers

Intervention Approaches (OTPF)

Approach	Focus	Example
Create/Promote	Health promotion; enrich context	Wellness program, ergonomic education
Establish/Restore	Remediate; develop new skills	Strengthening, cognitive retraining
Maintain	Preserve current abilities	Home program for chronic condition
Modify (Compensate/Adapt)	Change task or environment	Adaptive equipment, environmental modification
Prevent	Reduce risk of dysfunction	Fall prevention, joint protection

7. Professional Ethics

AOTA Code of Ethics Principles

Beneficence

Act in best interest of client; promote well-being

Nonmaleficence

Do no harm; avoid actions that could cause harm

Autonomy

Respect client's right to self-determination and choice

Justice

Fair and equitable treatment; advocate for access

Veracity

Truthfulness; provide accurate information

Fidelity

Faithfulness; maintain trust and confidentiality

Ethical Issues in Practice

Issue	Considerations
Informed Consent	Client must understand and agree to treatment; capacity considerations
Confidentiality	Protect client information; share only with consent or legal requirement
Scope of Practice	Practice within competence and legal boundaries
Dual Relationships	Avoid personal relationships that could impair objectivity
Competence	Maintain and update knowledge; seek supervision when needed

OT/OTA Supervision

OTR (Occupational Therapist Registered): Responsible for evaluation, intervention planning, outcomes
OTA (Occupational Therapy Assistant): Implements treatment under OTR supervision; contributes to evaluation data collection
OTR must supervise OTA; level varies by setting and regulations
OTA cannot independently evaluate, interpret, or modify treatment plan
Both are responsible for maintaining competence and ethical practice

8. Laws & Regulations

Key US Healthcare Legislation

Law	Key Points
HIPAA (1996)	Privacy of health information; patient rights; security requirements
ADA (1990)	Prohibits disability discrimination; reasonable accommodations
IDEA (2004)	Free appropriate public education; IEP; related services (including OT)
Section 504	Anti-discrimination; accommodations in federally funded programs
Medicare/Medicaid	Coverage requirements; documentation standards; reimbursement

IDEA and OT in Schools

OT as Related Service: Supports educational goals, not medical model
IEP (Individualized Education Program): Team-developed plan; measurable goals
LRE (Least Restrictive Environment): Educate with non-disabled peers to maximum extent
FAPE (Free Appropriate Public Education): Services at no cost to family
Child Find: Obligation to identify children who may need services
Ages 3-21; Part C (Early Intervention) for 0-3

Philippine OT Regulation

RA 5680 (1969) - OT Law of the Philippines

Regulates the practice of OT in the Philippines
Establishes Board of Occupational Therapy
Sets requirements for licensure
Professional Regulation Commission (PRC) oversight
Continuing Professional Development (CPD) required

Reimbursement Considerations

Medical Necessity: Services must be reasonable and necessary
Skilled Services: Require OT expertise; not routine care
Documentation: Must support medical necessity
Prior Authorization: May be required for some services
Billing Codes: CPT codes for specific services

Key Takeaways for the Board Exam

✓Evaluation components: Occupational Profile + Analysis of Occupational Performance
✓Top-down approach: Start with occupations, then explore contributing factors
✓FIM scoring: 7=complete independence, 1=total assist
✓SOAP: Subjective, Objective, Assessment, Plan

✓SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound
✓Ethics principles: Beneficence, Nonmaleficence, Autonomy, Justice, Veracity, Fidelity
✓IDEA: OT is a related service; supports educational goals
✓OTA supervision: OTR responsible for evaluation and plan; OTA implements under supervision

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Assessment Topics

OT Evaluation Process Types of Assessments Standardized Assessments Documentation Standards SOAP Notes Treatment Planning Professional Ethics Laws & Regulations

OT Study Notes

• Foundations & Theories • Pediatric OT • Physical Dysfunction • Psychosocial OT• Assessment & Documentation