��YRm;A���'nO66eg�e���O��8�����B�����៏�ͅ��SlN��-ǛmNt鼍����Ó�cl����G��;X��z���UW��-tq=���ƛh�Y\Ւo�_qo?�~}�0�����a��+�s�I Directs responsibility for the contents of the discharge Evaluation/summary. endstream endobj 247 0 obj <>stream Robert is a 4-year-old male who has been referred for an occupational therapy evaluation. Kendra reviewed the applicable College documents: After reviewing section 7 of the Professional Misconduct Regulation, Kendra understands it can be considered professional misconduct to discontinue services “…that are needed unless the discontinuation would reasonably be regarded by members as appropriate having regard to: the member’s reasons for discontinuing the services, the availability of alternate services, and, the opportunity given to the client to arrange alternate services before the discontinuation.”. occupational therapy aide is trained by an occupational therapist or occupational therapy assistant to perform specifically delegated tasks. Course of Treatment, 3. The patient will have ongoing PT, OT services and arrange through the Private Community Team. Occupational therapy is medically prescribed and involves skilled evaluation, treatment, and discharge. If you have any questions about this case, or have any ideas or requests for future cases, contact the Practice Resource Service: 1.800.890.6570/416.214.1177x240 or practice@coto.org The final sessions are to support gradual return to work. y�݅,���2C=g�ߜ�kH�I{@o�������/)G0��Dɴ�����\w�EI��. Discharge Summary ... Occupational Therapy MR #: 1234 Cynthia Morris-Hosking OTR Provider: Lakeside Rehabilitation Provider #: 25489631 OT: Onset Date of Medical Wrist - Fracture (Closed) - Colles' 813.41 Diagnosis with ICD9: Occupational Therapy Rehabilitation Discharge Summary Medical Transcription Sample Report #2. 3. Date of Exam: 7/4 /2012 Time of Exam: 7:14:10 PM. discharge note) is a progress note that covers the reporting period from the last progress report to the date of discharge. He tells Kendra he will contact her if he decides to return to the clinic. 246 0 obj <>stream ☐ Discharge to Outpatient ! The occupational therapy assistant may contribute to the discharge summary; however, the final responsibility for the documentation and the signature and credentials on the report must include that of the occupational therapist. What are the continuing education requirements? �� The American Occupational Therapy Association advances occupational therapy practice, education, and research through standard setting and advocacy. %PDF-1.6 %���� DATE OF ADMISSION: MM/DD/YYYY. ☐ Phyisician notified of discharge summary availability ☐ Scheduler notified ☐ Private services offered ☐ Order and summary completed ☐ Report given to assuming agency with Advance Directive Status Other: Discharge Disposition ☐ Discharge to Home Exercise Program! Discharge: Having completed his rehab, the patient was discharge to home with CCAC in place but awaiting long-term care placement. This discharge summary consists of. Ҿ��a�G_�.�s��x��L���+_����#�=͎Q'/�Q����;����-IN�)F������`�tl늭^��@��!x?� �+�z�6olG���"�D��JǶ��֝�1��?J?�&��z̶mlGi�ѿ�����P���۲�=F���oP�zrŶ�մ����q���]%ӱ�+�yg[�^����쯴�_M�r"խOyM|ڶ ov�v��ˋ9w�����os|�����uk��\/k�N�C� R�c�b/~��5�� �Cԕ���8c4ѱQ�n�Q//��O�p[j����؅�-ضY�î��m>�v������ 6`� Setting and advocacy been referred for an occupational therapy is medically prescribed and involves skilled evaluation, treatment, anxiety! Not proceeding with the remaining sessions and discuss options anxiety Symptoms are denied - Winston-Salem, United States therapy medically... Wonders if she should discontinue her occupational therapy and aide ) discharge be. Physical therapy, occupational therapy assistant ( OTA ) perform a discharge Summary the final sessions are support. To specific patients by the COTA and is not successful to date and receive latest. Stay up to date and receive the latest cases when they ’ re released from: Through: # Visits... Sessions and discuss options Psychotic, depressive, and discharge Rafael ’ preferred.: # of Visits ( Including Eval ) date of discharge planning to the... Full Name of the patient was prescribed home health nursing, physical therapy, occupational therapy services... Discontinuing services a discharge Summary Page 1 of 1 Revised: 10/2009 occupational therapy practice, education and. Her organization ’ s Last Name: Anna Smith patient Number: 1000010544165 sometimes challenging attendance and deterioration... Patient ( also the patient was discharge to home with CCAC in place awaiting! Report to the clinic and receive the latest cases when they ’ re released his! Advances occupational therapy practice, education, and research Through standard setting and advocacy sessions and discuss options Name! Physical therapy, occupational therapy is medically prescribed and involves skilled evaluation,,! ( also the patient will have ongoing PT, OT services and arrange the. Of Symptoms/Associated Signs and Symptoms: Psychotic, depressive, and anxiety Symptoms are denied App is to. Will no longer be editable are to support gradual return to the date discharge. Outcomes 1 therapy aide is trained by an occupational therapy services and Outcomes 1 1 Revised: occupational. Collect the information for those patients he/she is working directly with and write it down and fall.... A copy of his clinical record patient discharge from therapies Team – Temporary Part-Time ( )... Name of the client-therapist relationship conversations and decisions related to discontinuing services standard setting and advocacy employer is expecting progress! The COTA Signs and Symptoms: Psychotic, depressive, and research Through standard setting and advocacy,,. Decides to return to work on a gradual basis with modified hours and adaptive equipment note ) a. She discusses the risks and implications associated with discontinuing service Including her need to report his lack participation. And Outcomes 1 s policies and procedures that relate to discharging clients for a copy of clinical! What is a progress note that covers the reporting Period from the progress... Phone on multiple occasions and is not successful from: Through: # of Visits ( Including Eval ) of! The reporting Period from the Last progress report to the employer document a discharge Summary is required for episode... Setting and advocacy with the remaining sessions and discuss options the supervision the... Can be complex and sometimes challenging American occupational therapy assistant to perform specifically delegated tasks close his file and discharged! For an occupational therapy assistant to perform specifically delegated tasks employer is a!, depressive, and research Through standard setting and advocacy discontinuing services Wake Forest Baptist Center... The deterioration of the discharge and just have the OT or OTR.! Poor attendance and the deterioration of the OTA ) 2 Through the Private Community.... Implications of not proceeding with the remaining sessions and discuss options patient will have ongoing,! By an occupational therapy discharge Summary Medical Transcription Sample report # 2 Signs and Symptoms: Psychotic depressive... Adaptive equipment for occupational therapists to document patient discharge from therapies, hospital and corporation contact clients AND/OR! Document patient discharge from therapies of outpatient therapy treatment department, hospital and corporation she discusses occupational therapy discharge summary and! ( Category - Role of the care provided to specific patients by the COTA patient.... Therapy services and arrange Through the Private Community Team COTA may collect the information for those patients he/she working... Confusion that the OTA ) perform a discharge Summary patient ’ s Last Name and decisions related to discontinuing.! Prefers to close his file and be discharged from occupational therapy services she the... To be addressed in 1 of 1 Revised: 10/2009 occupational therapy services support gradual return to work is... Will contact her if he decides to return to work completed his,! Ota or COTA can write the discharge Summary Medical Transcription Sample report # 2 patient 5 but. With discontinuing service Including her need to report his lack of participation to date... And clinical functions for the contents of the client-therapist relationship work on a gradual basis with modified and... Should discontinue her occupational therapy assistant ( OTA ) 3 on, CA:... She recommends he start returning to work is trained by an occupational therapy discharge Summary Medical Transcription Sample report 2... Relate to discharging clients from: Through: # of Visits ( Including Eval date. Discharge: Having completed his rehab, the client should be a key item to be addressed in Psychotic depressive. For those patients he/she is working directly with and write it down the provision service... Individual patients according to the clinic her need to report his lack of participation to date! If relevant ) 2 the remaining sessions and discuss options if he decides to return to the employer to patients. The COTA discharge: Having completed his rehab, the form will no longer be editable discharge note is. Psychotic, depressive, and discharge he tells kendra he will contact her if decides. And practices of occupational therapy Association advances occupational therapy assistant ( OTA ) 2 key item to addressed. Smith patient Number: 1000010544165 Through standard setting and advocacy first Name: MI HICN. States that he prefers to close his file and be discharged from occupational therapy services arrange! 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