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Documenting Occupational Therapy Practice

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Tone
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important to monitor your tone, no all caps, don’t assume the person you are in correspondence with knows everything you know
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Active Voice
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put client first than the action Self-care skills have been a concern of this client. Client reported concerns with her self-care skills
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Nondiscriminatory Language
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Be aware of personal biases “Person first” language Use adjective form of population descriptions Not acceptable to use masculine/feminine pronouns to refer to both sexes Write occupational therapist versus therapist
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Memo’s
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See pg. 5 in Sames for sample formats Pay attention to grammar and spelling 1-inch margins, double-spaced, 12-point font sized, Times New Roman Limit to one page if possible
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Letters
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Similar to memos; even more formal tone Several formats but be consistent Get to the point Use formal title of person you are addressing
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E-mail
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Five EMAIL commandments E- email only those to who your message pertains to M- make a point of responding promptly A- always use spell check I- include your phone number in your message L- learn that email is for work not for personal use Make sure you address the recipient first
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Buzz words
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trendy or popular words in OT the current buzz word is function/functional improvements and evidence/evidence based, these buzz words emphasizes the importance of OT in our documentation.
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Red Flag Word
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example maintaining, we do not get reimbursed for maintaining, we strive to improve or increase the function.
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Jargon
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be careful with jargon and abbreviations in documentation, can impact your reimbursement. Use language specific to OTPF.
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Need to Know Abbreviations and Symbols
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BOX 2.2 – Abbreviations Related to Frequency BOX 2.3 – Abbreviations Related to Body Parts and Diagnoses BOX 2.5 – Range of Motion Abbreviations BOX 2.6 – Abbreviations for Clinical Procedures
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Document with CARE
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Clarity Accuracy Relevance Exceptions
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When writing a goal they must be
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*measurable-how will you know when the goal has been met *realistic *just right challenge
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Goals are established in collaboration with the client but ultimately the responsibility is of the ______.
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OT
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Goal Directions are influenced by the frame of reference the OT uses as well as the _______________.
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type of setting
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OTPF Intervention Approaches
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Create or Promote Establish or Restore Maintain Modify Prevent
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Outcomes of Goal Directions
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Occupational Performance Client Satisfaction Role Competence Adaptation Health and Wellness Quality of Life
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Goal Directions
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Restorative Goals Habilitative Goals Maintenance Goals Modification Goals Preventative Goals Health Promotion Goals
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By December 15, 2014, client will fasten three buttons in two minutes using button hook with minimal verbal cues.
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Restorative Goal
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Emma will demonstrate increased functional mobility by independently moving from prone on the floor to standing by November 15, 2015.
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Habilitative Goal
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For the next 6 months, client will continue to live in her own home with minimal assistance of the home health aide.
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Maintenance Goal
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By August 12, 2015, Paul will open boxes, cans, and bags with the use of adaptive equipment as needed, so that he can independently prepare meals at home.
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Modification Goal
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Preventive Goal
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By discharge, client will independently demonstrate proper body mechanics while lifting.
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By the end of this class, parents will demonstrate minimal competency in infant massage.
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Health Promotion Goal
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Goal Specifics
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Long-Term/Discharge Goals Short-Term Goals Acute Care Goals- short time with patient in acute care, usually only do short term. Action Verbs (see Box. 11.1) Verbs to Avoid (see Box 11.2)
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Ways to measure change
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See Box 11.3 Frequency or Consistency Duration Assistance-how much assistance the OT gives Quality of Performance Level of Complexity Participation Other- different settings
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Assistance levels
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100%-dependent 75-99%-max 25-50%-med 1-25%- min
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Formats of Goal Writing
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ABCD FEAST RHUMBA SMART
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ABCD(E)
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Audience- the client, or caregiver if a pediatric environment, or spouse Behavior-what the audience will do Condition- of where the behavior will be performed, or how Degree-how well they will do it Expected Time-expected timeline
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FEAST
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function- what is the occupational performance area you are working on expectation- first part of the goal… the client will___ action- what the patient will do, more specific specific conditions- where and how the behavior will be accomplished timeline- when
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RHUMBA
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Relevant/Relates- is your goal relevant to what you identified as the needs of the client How Long-time line Understandable- can anybody understand it Measurable- how will you know when its accomplished Behavioral- observable Achievable- just right challenge
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SMART
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Significant (and simple)- is the goal significant enough to have an impact on the patient Measurable-identifying the level of assistance Achievable Related- short term and long term goals relate Time-limited
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Documenting interventions
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Daily Notes/Contact Note/Encounter Note-one time note after intervention Progress Note/Progress Report-sums up multiple sessions, how frequently they are done is dependent on facility Three Main Methods of Documenting Intervention SOAP DAP Narrative- paragraph, not broken down into sections but contains all info a SOAP not would Role Delineation-between the COTA and OT, typically the OT must sign off any notes the COTA wrote
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SOAP Notes
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Subjective- all information obtained from the client, quote them if needed, relevant info only Objective-anything you observed, ie performance of client, write it chronologically, what was the purpose, how was it completed Assessment-interpret the information from the S&O, what does it mean. SO WHAT? Rehab potential. Plan- identifying what your plan going forward will be, how long will you see them, what adaptive tools will the patient use.
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DAP Notes
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description- subjective and objective assessment plan
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FIP Notes
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findings- objective and subjective interpretation- assessment plan
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Other Documentation Methods for Intervention
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progress flow sheets attendance logs photographic and video documentation
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Electronic Health Records
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EHR
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HIPPA security rule
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keep in in mind precautions
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AA
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active assist
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AAOx3
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alert, awake, and orientated to place and person times three
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AE
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above elbow
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AEA
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above elbow ampuation
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AIDS
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acquired immunodeficiency disorder
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AK
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above knee
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AKA
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above knee amputations
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AP
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anterior-posterior
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APGAR
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appearance, pulse, grimace, activity, respiration
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AV
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arteriovenous; artioventricular; aortic valve
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BE
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below elbow
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BEA
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below elbow amputation
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BK
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below knee
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BKA
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below knee amputation
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BP
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blood pressure
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bpm
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beats per minute
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BS
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breath sounds; blood sugar; bowel sounds
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BUE
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both upper extremities
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CABG
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coronary artery bypass graft
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CAD
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coronary artery disease
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CC or C/C
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chief complaint; carbon copy
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CCU
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cardiac care unit
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CHF
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congestive heart failure
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CICU
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cardiac intensive care unit
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CN
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cranial nerve
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CNS
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central nervous system
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c/o
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complains of
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COPD
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chronic obstructive pulmonary disorder
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CSF
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cerebrospinal fluid
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CVA
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cerebral vascular accident
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DF
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dorsiflexion
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DIP
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distal interphalangeal joint
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DM
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diabetes mellitus
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DOB
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date of birth
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DTR
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deep tendon relfex
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DVT
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deep vein thrombosis
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ECG/EKG
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electrocardiogram
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ECHO
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echocardiogram
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EEG
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electroencephalogram
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EENT
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ears, eyes, nose, and throat
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ER
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emergency room or external rotation
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ETOH
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alcohol use or abuse
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FAS
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fetal alcohol syndrome
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FBS
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fasting blood sugar
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FTT
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failure to thrive
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G
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good
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G-tube
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gastrostomy tube
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GA
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gestational age
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GERD
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gastroesophogeal reflux disease
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GYN
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gynocology
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H/A or HA
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headache or hamstrings
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HB or Hb or Hgb
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hemoglobin
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HBP
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high blood preasure
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HEENT
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head, ears, eyes, nose, and throat
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HLT
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heart lung transplant
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HOH
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heard of hearing; hand over hand
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H & P
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history and physical
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HPI
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history of present illness
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HR
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heart rate
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Ht
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teight
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HTN
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hypertension
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ICA
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internal carotid artery
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ICH
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intracranial hemorrhage; intracerabral hemorrhage
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ICP
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intracranial rpressure
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ICU
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intensive care unit
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ID
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infections disease
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IDDM
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insulin-dependent diabetes mellitus
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IM
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intramuscular
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Indep
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independent
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Inf
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inferior
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IP
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interphalangeal
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IR
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internal rotation
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Lat
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lateral
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LCA
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left carotid artery
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LD
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learning diability
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LE
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lower extremity
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LLE
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left lower extremity
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LMN
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last menstraul period
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LOC
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loss of consciousness
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LUE
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left upper extremity
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MCA
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middle cerebral artery
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MCP or MP
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metacarpal phalangeal
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Med
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medial
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Mets
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meastisis
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MH
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mental health
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MI
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myocardial infarction
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MRSA
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methicillin resistant staphylococcus aureus
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MVA
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motor vehicle accident
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N
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normal; nausea
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N/A
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not applicable; not available
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NG
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nasogastric
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NICU
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neonatal intensive care unit
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NKA
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no known allergies
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NKDA
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no known drug allergies
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N & V
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nausea and vomiting
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OA
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osteoarthritis
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OD
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overdose
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ORIF
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open reduction internal fixation
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PARA
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paraplegia
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PH
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past history
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PI
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present illness
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PICA
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posterior inferior cerebellar artery; posterior inferior communicating artery
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PICU
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pediatric intesnsive
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PIP
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proximal interphalangeal joint
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PLF
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prior level of function
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PMH
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past medical history
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Post
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posterior
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PWB
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person with AIDs
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QUAD
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quadriplegia
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RA
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rheumatoid arthritis
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RCA
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right carotid artery
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RLE
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right lower extremity
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r/o
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rule out
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RUE
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right upper extremity
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SCI
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spinal cord injury
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SD
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seizure disorder
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SOB
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shortness of breath
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S & S
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signs and symptoms
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Str
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strength
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Sup
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superior
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TBI
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traumatic brain injury
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THA
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total hip arthroplasty
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THR
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total hip replacement
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TIA
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transient ischemic attack
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TKA
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total knee arthroplasty
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TKR
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total knee replacement
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TPR
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temperature, pulse, and respiration
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TSA
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total shoulder arthroplasty
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UE
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upper extremity
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URI
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upper respiratory infection
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v.s.
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vital signs
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qd
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once a day
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bid
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twice a day
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BIN
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twice at night
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tid
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three times a day
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qid
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four times a day
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eod
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every other day
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i
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once a day
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ii
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twice a day
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iii
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three times a day
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1x/wk
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once a week
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2x/wk
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twice a week
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1x/mo
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once a month
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2x/mo
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twice a month
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________ must demonstrate services within the scope of practice.
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documentation
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Criteria for Avoiding Legal Actions
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1. be careful and objective 2. be timely, grammatically correct, legible, and correctly signed 3. be tamper-free
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6 acts prohibited by Medicare
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1. Making false claims for payment 2. Making false statements for payment 3. Billing for visits never made 4. Billing for nonface-to-face therapy services 5. Paying or receiving kickbacks for goods and services 6.Soliciting for, making an offer for payment, paying or receiving payment for patient referrals
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AOTA code of ethics applies to documentation
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Principle 6: “Occupational therapy personnel shall refrain from using or participating in the use of any form of communication that contains false, fraudulent, deceptive, or unfair statements or claims”