Position : Occupational Therapist
Occupational Therapy Practice Framework by performing an evaluation that includes an occupational profile of the patient's medical and therapy history; performs an assessment of occupational performance using standardized tests and identifies performance skills and performance deficits.
Develops a plan of care with measurable goals based on clinical reasoning and the interpretation of the data. Implements treatment interventions to address the inability to complete activities due to performance deficits with physical, cognitive or psychosocial skills.
Conducts re-evaluations to modify interventions as necessary to achieve goals and outcomes.
Discusses the plan of care with patient/caregiver and other appropriate healthcare team members. Identifies discharge planning needs that include psychosocial and environmental safety hazards and discusses needed modifications with caregiver and/or patient.
Completes clinical documentation within established time frame, following department policies and using only approved terminology and abbreviations.
Documentation meets all regulatory requirements and follows established formats. Patient charge documentation is completed within established time frame and follows current coding requirements for all payer sources.
Maintains current knowledge of coding/billing responsibilities.
Has a general awareness of payer sources and addresses limitations with the patient as appropriate; makes referral to patient financial navigator if needed to assist patient.
If it is determined the problems to be addressed are not within the scope of occupational therapy practice, a referral to another health care provider is initiated.