documentation course

[truthseeker]

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I am a PT and the rehab director at the hospital where I work. We have an OT who began working in a school system but is now working in a hospital and SNF. I find her documentation lacking and have recommended that she find a documentation course to upgrade her skills.

Does anyone here have a recommendation for a good course either online or DVD/CD that they are aware of?

 

[superCOTA]

Sometimes styles and requirements vary between facilities....

You probably did this already but, perhaps reading / getting guidance from some patient evals from past employees?

 

[truthseeker]

Sometimes styles and requirements vary between facilities....

You probably did this already but, perhaps reading / getting guidance from some patient evals from past employees?

Thanks. I understand that. We really haven't had previous employees in OT. She has been here for years.

I assume that objective measures need to be taken and measurable goals set, similar to PT and SLP notes. The notes should reflect the skilled nature of the service and demonstrate that only an OT can process and perform the service. in other words, simply saying that "the patient is unable to dress independently. skilled OT to continue" would be unacceptable. No commentary on what part of dressing, why they couldn't, for example, button buttons. Is it coordination, loss of sensation, weakness, vision problems, motor planning/sequencing???? Those would seem to me to be the nuggets that make the bolded statement OT rather than a CNA or my mom saying that they can't dress themselves.

No ideas on a DVD or online course? anyone . . . anyone . . .