CONTENT AND PROCESS OF DOCUMENTATION IN OT/PT
| Record | Permanent Record | ||
| Referral form Datebased Evaluation | DataBase Initial | ||
| Summary | |||
| Evaluation Records | |||
| Treatment Plan | Progress Report | ||
| Running Progress Notes | |||
| Re-evaluation Records | Re-evaluation Reports | ||
| Running Progress Notes | Progress Report | ||
| Discharge Report |
Functions
of OT/PT
OT/PT
is rehabilitating procedure guided by qualified professionals.
Need
qualified prescription.
Uses
various therapeutic means to cure.
Tries
to gain physical and mental response.
Uses
different modalities of treatment to make patients functionally viable.
Work
in close relationship with other team members as desired/required.
Make
patient return to the possible physical mental, social & economic
independence.
Types
of record to be maintained by therapist
1.
Keep records properly with agency also where employed with daily
appointment record of patient for treatment.
2.
Equipment purchase/repair/service records.
3.
Keep patient’s financial records for audit in terms of:
a)
Date of commencing treatment
b)
Services obtained
c)
Payments received by organization
d)
Balance of account if any
Document
of integrity of records
Accurately
documenting records.
Policy
(time of records, time duration, true, accurate, complete records)
Correct
billing of treatment
Protect
evidence if any chances of litigation.