Occupational therapists and occupational therapy assistants1determine the appropriate type of documentation structure and then record the services provided within their scope of practice. Occupational therapy documentation provides a record of the practitioner’s ac-tivity in the areas of screening, evaluation and reevaluation, intervention, and outcomes (AOTA, 2014b) in accordance with practice guidelines and payer, facility, and state and federal guidelines and requirements. 97165 - occupational therapy evaluation - 1 unit. Physical and Occupational Therapy Documentation Page 3 of 4 Visit/Daily Treatment WSI requires documentation for every visit, which may be in the ... American Journal of Occupational Therapy, 68, S1–S48. Create daily notes with a consistent structure and flow typically receive therapy DEFENSIBLE DOCUMENTATION Key Elements of Assessment Information “Assessment” • World Dictionary: “to judge the worth, importance, etc., of; evaluate” • Synonyms: appraise, determine, check, gauge, judge, weigh, apprise • Is a critical element for demonstrating the 7 Principles for Improving your Pediatric OT Documentation & SOAP Notes. Documentation is a huge part of our role as OT practitioners. Course Description Today’s healthcare reimbursement process presents challenges to both physical therapists & occupational therapists. Quantity. Occupational Therapy Assistants Do's and Don'ts of Documentation: Tips From OT Managers Doing rewarding work with clients—helping people to lead more meaningful lives—comes with a less fun aspect of the job: documenting those moments. Now, if you want to be more effective and efficient as a pediatric occupational therapist, here's more information on the seven essential principles you should use as a guide for creating defensible documentation. I … Defensible Documentation in the Acute Rehabilitation Setting $ 40.00. Documentation of occupational therapy services is necessary whenever professional services are provided to a client. Since documentation time is not reimbursable, we have to also be efficient, all while actually producing therapy notes that are defensible and complete. Defensible Documentation - MiOTA Documentation of occupational therapy services is necessary whenever professional services are provided to a client. Occupational therapists and occupational therapy assistants1 determine the appropriate type of documentation structure and then record the services provided within their scope of practice. 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