12. How often do I need to document treatment?
The Board requires documentation of each intervention session; in other words, there must be an intervention note for each intervention session provided to the client. As stated in §372.1(g)(2) of the OT Rules, “The licensee providing occupational therapy services must document for each intervention session. The documentation must accurately reflect the intervention, decline of intervention, and […]
11. Must an OTA have notes co-signed?
No, the OT Rules do not require that the OT co-sign the OTA’s notes. However, in each intervention note, the OTA must include the name of an OT who is readily available to answer questions about the client’s intervention at the time of the provision of services. The OT in the intervention note may be […]
10. Can I co-treat?
You will have to look at what the payer allows. The Board has no rules on this.
9. Can an OT see a mental health patient such as someone with PTSD or Schizophrenia without a doctor’s referral?
If a patient/client/individual is in the hospital with acute PTSD, then it is a medical condition and it would be necessary to have a script. If seen in the community that says that the individual is stable enough to be in the community and therefore no script is necessary. Not just PTSD but you can […]
8. The Previous OT did not sign the discharge and now I’m faced with the paperwork. What do I do?
You can sign a “late entry” a type of summary note that tells what facts you are aware of according to the patient’s file. The patient’s last treatment was x date, was discharged on x date and is no longer receiving OT services, then sign the discharge with the date you write the note. The […]
7. Do I have to be certified before I provide a physical agent modality?
At all times, it is the responsibility of the occupational therapy practitioner (OTs and OTAs) to demonstrate competency in all physical agent modalities used for the provision of occupational therapy services. Occupational therapy practitioners must know how to perform and demonstrate proficiency in, as noted, any physical agent modalities used; however, please note that the […]
6. Can OTs apply prescription topical medications, such as those used in iontophoresis?
Since occupational therapy practitioners do not administer medications, the Board recommends that the patients bring the medication, apply the medication during the occupational therapy treatment, and take it home with them.
5. Can the OTA write the discharge?
No. The occupational therapist must review any information from the occupational therapy assistant(s), determine if goals were met or not, complete and sign the discharge documentation and/or make recommendations for any further needs of the patient in another continuum of care.
4. Can the occupational therapy practitioner sign off for an Activities Director?
No. The activities director is not providing occupational therapy services. Unless the activities director is working with a client, under the direct, on-site supervision of the OT, and unless that client’s activity is part of a prescribed OT plan of care, the OT should not sign off on the activities director’s services.
3. Can an OT or OTA supervise the Restorative Nursing Program?
No. The OT cannot run the restorative nursing program, but can make a recommendation for the patient to participate in the restorative nursing program and/or any specific recommendations for the patient as part of the discharge from skilled services.