ot documentation cheat sheet

My vision (and Ill admit, its a grand one) is to help you create treatment notes that clearly communicate the skilled OT care you providedwithout making you lose your mind in the process. 4. BARS: Easy Tool to Assess for Agitation in Patients for Occupational Therapy, 60 Tips to Improve Your Documentation as an Occupational Therapist, Occupational & Physical Therapy Levels of Assistance, Drop Arm Commode and other Bathroom Toilet Shower DME Letter of Medical Necessity for Occupational Therapy, Save $150 off your continuing education subscription: Click Here, Should You Hire a Friend? Include short-term and long-term goals (evaluation, re-assessment). Be ethical, dont make up stuff or fudge details. and needed to get a good understanding of what is going on with the patient, what you currently are working on, how do you feel about their progress and then what are you hoping to do next visit or in the near future? A new goal writing method called the C.O.A.S.T. Here are a few things you can generally leave out of your notes: Details are great, because they help preserve the humanity of our patients. If a detail does not contribute to the story you are tellingor, in OT terms, contribute to improving a patients functionyou probably dont need to include it . Subjective is personal. I am thinking about the occupational profile and how AOTA is advocating for its use in all evaluations. These are real-life documentation examples. occupational therapy fieldwork cheat sheet. What conditions are necessary for the client to achieve the tasks. Create a custom ot documentation cheat sheet pdf 2010 that meets your industry's specifications. Footnotes. Take a peek at the OT Decision Chart - Evaluation Tool. He was also issued a scar pad to be worn overnight, along with a tubular compression sleeve. Patient educated on purpose and instructed in Codmans exercise x 1-minute x 5 RUE clockwise, then counter clockwise. OT cheat sheets 33 Pins 5y A Collection by Alexis Denmon Share Similar ideas popular now Occupational Therapy Physical Therapy Pediatrics Hand Therapy Physical Therapy Student Elementary Physical Education Elementary Pe Physical Education Activities Occupational Therapy Assistant Occupational Therapy Activities Pediatric Physical Therapy The two most important PT/OT documentation requirements are demonstrating that care is (1) medically necessary and (2) skilled. You are right. This section isnt rocket science. PTM has one of the largest databases of outpatient PT/OT provider productivity, visit and payment information, with more than 5 million visits. OT developed HEP and patient instructed in self ROM/stretches to increase I with HEP for BUE exercises. Zip. Improved range of motion and stability of her right arm confirms that her use of shoulder home exercise plan is improving her ability to use her right upper extremity to gain independence with self care.. But, a really good notedare I say, a perfect noteshows how the two interact. By end of session, patient stated, I have noticed I am able to hold it in longer.. Patient completed x 15 minutes with PT facilitating interval training of varying resistance 1-2 minutes. 97162: PT evaluation - moderate complexity. The ready to print versions can also be found in our Therapist Toolbox - Free to download for all . Services that do not require the performance or supervision of a therapist are not considered skilled even if they are performed by a therapist. In regard to occupational therapy servicing the rehabilitative patient within the skilled nursing facility (SNF) setting the occupational therapy practitioner can play a tremendous role in enabling short term patients and long term residents in living life to the fullest. Will require further skilled services to increase weakened RLE. Head over to: Documentation Domination for OT Practitioners Working with Older Adults or check out the OT Flourish Membership - it has more documentation tips and goal writing examples, as well as OT treatment ideas, education videos, clinical resources, patient handouts, assessments and support! Our notes help us track patient progress, communicate with other healthcare providers, and defend our rationale for our treatment choices. The OT Toolbox assumes no responsibility for errors or omissions that may appear in the Website. Fort Collins, CO: Center for Innovative OT Solutions. For more complete info, see John Gruber's original spec and the Github-flavored Markdown info page. In: StatPearls [Internet]. Episode 4/5 of the documentation series: PLAN. Right upper extremity: Right shoulder, elbow, forearm, digit range of motion all within normal limits on all planes. Occupational Therapy for Children and Adolescents by Jane Case-Smith; Jane Clifford O'Brien. Not only is the logic of clinical reasoning reflected in documentation, but documentation itself shapes the process of clinical reasoning. Cutting goals _____will snip with scissors in 4 out of 5 trials with _____ assist and _____% verbal cues to promote hand eye coordination for participation/ success in school setting. why or why not. Powerful practice: A model for authentic occupational therapy. Documentation standards across common school-based therapy types The main therapy associations all provide standards for documentation within their specialty. Progress Note Statements on Goals. _______________________________________________________________________________________________________________________________________________________, Want to DOMINATE documentations? But the reality of writing an occupational therapy SOAP note, and other documentation, in the clinic is actually a lot simpler than it sounds. Skill in documentation is the hallmark of a professional approach to therapy and is one of the characteristics that distinguishes a professional from a technician. OTA releases a range of documents to members and the public, as to expected standards of . When I made a note I was happy with, I would print a copy and keep it on my clipboard. When there are two units of the same service remaining to be billed, and the PT/OT and the PTA/OTA each furnish between 9 and 14 minutes of a 15-minute timed service where the total time of therapy services furnished in combination by the PTA/OTA and PT/OT is at least 23 but no more than 28 minutes, one unit of the service is billed with the CQ/CO modifier (for the unit furnished by the PTA . Pt will complete toileting with CGA and toilet transfer with min assist x1 person. Tactile, verbal and visual cues needed to isolate targeted muscle groups. Written specifically for occupational therapy assistants, The OTA's Guide to Writing SOAP Notes, Second Edition is updated to include new features and information. Written by Laurie Ray, MPT, PhD, who has over 18 years of experience in school-based practice and is a state-level PT consultant for public schools. OTs can also recommend adaptive equipment and home modifications, if needed. Here is a brief review of the S.O.A.P note format: S is for subjective information which is what the client/family states or presents as relevant to therapy, (think of it as your clients current status, behavior, or answers to your questions), O is for objective which is what you and the client did together to address their goals, (think of it as measurable, quantitative, and observable actions during the session), A is for assessment which is how the client did or how they responded during the treatment, (think of it as adding validity and interpreting the information written in the S and O section), and. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. I believe after the first 72 hours, Medicare only requires a note every 24 hours. I see what you are talking about. . S is for specific condition. These acronym structures can also help you, as the practitioner, in your future paperwork needs for progress reporting, re-assessment, and goal writing that is specific to each of your clients. Patient arrived at OT for engagement in incontinence management including PMEs to reduce urinary urgency. . The treating diagnosis is not always . The basic format for a SOAP note is as follows: Many times this is not laid out in this manner through our documentation systems and we get a big ol blank box to write our daily note in. She has been practicing occupational therapy in the same school district for 20 years. DOCUMENTATION FRAMEWORK: OCCUPATIONAL THERAPY AUSTRALIA (JANUARY 2018) 3 1 Introduction Occupational Therapy Australia (OTA) develops a range of documents to fulfil different purposes including practice standards, lobbying and advocacy. Available from:. PT assessed progress as follows: Increase of 4 degrees R hip flexion, 3 degrees hip abduction and 2 degrees in extension post ther ex when compared to previous session. Do not include your opinions, insight, interpretations, draw connections or anything like that (belongs in assessment). Patient educated and instructed in R hip exercises to increase R hip ROM/strength for improved balance, pain reduction, as well as core strengthening to reduce compensatory strategies for improved posture. 2. Affiliate links or relationships will be disclosed if there is any compensation for products mentioned on our site. Healthcare providers retain responsibility to submit complete and accurate documentation. PT provided cues to maintain hips in neutral vs. add during task, cues to maintain SPM >55, cues for pursed lipped breathing. With the current changes in healthcare, proper documentation of client care is essential . Instructed in how to propel w/c over carpet and thresholds of home safely. I see your sample above did not do this despite that being the current recommendation to do so. Patient trained in the following exercises using moderately resistive putty in order to increase gross grasp and various pinches: gross grasp, opposition, abd/add, tip pinch. Save my name, email, and website in this browser for the next time I comment. Can use as a documentation scrap sheet during chart review and eval. Sutures were removed and wound is healing well with some edema, surgical glue, and scabbing remaining. Regular price $27.00 Sale price $17.00 Sale. Example: Documentation in School Based Practice Part 1: Overview ( Occupational Therapy ) 2,640 views Apr 15, 2017 21 Dislike Share CallOTChrissy 5.16K subscribers This video provides an overview of the. Include any precautions to be taken with the client. Description of ot documentation cheat sheet pdf Occupational Therapy Common Abbreviations Cheat Sheet by David Pollack (David pol) via cheatography.com/2754/cs/7610/ Abbreviations PA Decreased Right IncreasedRadDev Radial Deviation Assisted. No one program will "fix" the problem, let alone make auditors happy. We tend to simply write: Patient tolerated therapy well. Or we copy and paste a generic sentence like: Patient continues to require verbal cues and will benefit from continued therapy.. But, weve all seen notes with way too much unnecessary information. Patient reported no increase in pain. Your email address will not be published. Every setting is unique though, so definitely structure the note in away that works for your particular situation! Assessed For example, you can say any of the following to get your note started: In sentence one, youve already begun to justify why youre there! Verbal/visual/tactile cues for increased recall, problem solving, sequencing or overall technique. We can use this section to highlight the shared decision making between you and the patient regarding the plan for the next visit. Do a search on allnurses for Daily skilled documentaion guidelines. Include the clients response to treatment such as their attitude or cooperation. We compiled over 100 assessments you can use to gather the most helpful data possible. [Updated 2022 Aug 29]. With over 80+ "quick phrases" and therapist-designed forms to choose from, the software includes Occupational Therapy templates that can easily be tweaked or customized. Legs - use your legs, not your back, arms, or shoulders. e.g.. Task adapted and modified in response to patients complaints, however, patient with increased pain to 8/10 with stretching. In one setting, I created an eval checklist, made copies of it, and used it to take notes so I always had all of the info handy. Extraordinary Limited Time Deal! Patient arrived at therapy with RLE weakness and decreased heel strike during assessment of gait. FREE NBCOT Exam Prep Course Enroll Now! Treasure Island (FL): StatPearls Publishing; 2022 Jan-. To do so is infringement of copyright law. Instead, consider something like: Patients reported improvements in tolerance to toileting activities demonstrate effectiveness of energy conservation techniques she has learned during OT sessions. Occupational therapy forms and notes are not only documents that patients use to file insurance claims, but they are also essential tools in helping track patient progress. Post surgery, patient complains of 2/10 pain at rest and 7/10 shooting pain at palmar region extending to second and third digits of right hand when working at his computer for extended periods of time and when doing basic household chores that involve carrying heavy objects (like laundry and groceries). Where to Find FREE DME Supplies for OT Patients, 7 Tips For Success As A New Grad Occupational Therapy Practitioner, Medbridge and present a framework for defensible documentation, example of the content that is in the OT Flourish Membership, Documentation Domination for OT Practitioners Working with Older Adults, patient questions about plan, treatment or outcomes, reflections of progress or current problems, address how intervention is working toward goal, specific treatment given using skilled terminology, quantifiable information and compare to initial eval or previous sessions (give me some numbers not just for evals and progress notes! Not only do utilization reviewers hate that type of generic language, but it also robs us of the ability to demonstrate our clinical reasoning and treatment rationale! In the OTPF-4 are terms and definitions of specific skills followed by examples and ineffective examples. Through listening to this podcast series myself, I have also learned that just because our patient is not making progress, does not mean that your skilled services will be denied! If a . While there is no straightforward or universal standard when it comes to clinical documents, they are used by over 90% of health practitioners in the US and provide relevant insight concerning the patient's health experience. Patient instructed in L hip exercises to increase L hip ROM/strength for improved balance and overall pain reduction. Anticipate patient may progress more slowly due to diabetes in initial weeks, but BCTOQ reflects that the patient is not progressing as quickly as normal, and is at risk of falling into projected 10-30% of patients who do not have positive outcomes following carpal tunnel release. Social emotional impacts motivation, participation, effort, etc, Carryover of instruction by patient/staff/care partners, Be specific on modifications to treatment plan (or direction of treatment plan), Notifications, communications or referrals made to RN/MD/PT/SLP, etc that need to be addressed, Recommendations/plan for changes of frequency, duration, etc and why, Future trials (including equipment, strategies, etc) that you would like to address. e.g.. Reported pain scores, e.g., 6/10 pain, would go here as it is a clients subjective thing (pain is often considered to be subjective). J Smith Manager) Other clients are not legally identifiable Patient will benefit from skilled OT to address these deficits, adhere to post-op treatment protocol, and return to work on light duty for initial four weeks. Patient presents to skilled PT s/p fall in patients bathroom resulting in R sided hip pain and overall weakness. In the OT Potential Club, our OT evidence-based practice club, you can also access our library of documentation examples. If you have questions about your tax liability or concerns about compliance, please consult your qualified legal, tax, or accounting professional. I am going to be sharing what goes into a SOAP note, and then feel free to dig into this a little deeper by listening to each of the episodes of the OT Flourish Podcast with an amazing series with Dee and Cindy by Kornetti and Krafft Health Solutions. Podder V, Lew V, Ghassemzadeh S. SOAP Notes. She graduated from the OTA program at Caldwell Community College and Technical Institute in Hudson, North Carolina with an A.A.S degree in occupational therapy assistant. So, with all of that being said, lets talk about treatment documentation and the necessary components of such to provide evidence for the need of OT services while simultaneously providing a record of client progress and needs. In seated position, patient was instructed in LLE strengthening exercises to decrease left foot drop during ambulation prior to functional mobility task. PT facilitated patient to complete standing ther ex including heel raises with BUE support, using mirror for visual feedback to ensure proper form, 215. Will acquire ultra grip built up rim covers for trial at next visit to see if that is a better long term solution vs the tape. Documentation can get a bad rap, but I believe OT practitioners are uniquely poised to write notes that are meaningful to other healthcare practitioners and patients alike. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Observing However, a minimum of five users are required for Fusion's entry-level pricing package. That's because these planners rarely save time. May be organized chronologically (most intuitive), categorically, based on the assessment format (e.g., COPM), or whatever would make the most sense for the note. Patient completed standing Achilles stretch 3x 30sec with mod verbal cues for technique and to engage in pain free range. Name. School-Based OT Documentation Manual $ 19.99 This comprehensive manual for Pediatric OT Practitioners covers the A-Z of documentation in the school setting. PT educated patient in B hand strengthening exercises post estim to improve overall grip/pincer grasps. Treatment documentation needs to be provided to share all about your hard work as a therapist and how you make an impact and a difference in the lives of your clients and their families. For treatment notes, many therapists actually combine their assessment and plan sections, which is where you would find sentences like the ones I listed. PMID: 32047606; PMCID: PMC6979466. The next step in the PT/OT section is to decide what the primary diagnosis will be for the resident. If your patient tells you in the subjective section that they are not progressing as quickly as they would like, what did you, as the therapist, do to upgrade their intervention? How to Create a "Cheat Sheet" (Allowed Reference Sheet) Download Article parts 1 Choosing and Organizing Information 2 Constructing Your Sheet Other Sections Questions & Answers Tips and Warnings Related Articles References Co-authored by Jake Adams Last Updated: January 4, 2023 References A "cheat sheet" isn't for cheating at all. For example: Be careful not to go into the realm of assessment though! Patient progressed this session to standing wall squats with physio ball and min A, heel raises with BUE support and cues for posture. A therapist can assign treatment diagnosis codes. PT directed patient x 18 minutes requiring 2 therapeutic rest breaks due to complaints of fatigue and increased respiration. Auditors often rely on repetitive or otherwise poor documentation to deny a claim based on the conclusion that therapeutic exercise did not require the skills of a therapist. Patient was provided education regarding ergonomic setup at work and home, along with home exercise program, including active digital flexor tendon gliding, wrist flexion and extension active range of motion, active thumb opposition, active isolated flexor pollicis longus glide, and passive wrist extension for completion 4-6x/day each day at 5-10 repetitions. Your assessment should answer these questions: The assessment section is your place to shine! Each note should tell a story about your patient, with the subjective portion setting the stage. Plan should connect back to the assessment section. To help therapists and assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature of therapeutic exercise. Ask yourself: What did youdo to make the tx session skilled (not just what the patient did in the session dont exclusively list out completed activities/interventions)? When it comes to completing all of the daily tasks involved in a therapists day, documentation requirements can impact productivity. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Address 12. Patient arrived at therapy with 3/10 L hip pain. by. Past medical/surgical history: anemia, diabetes, right open carpal tunnel release surgery on 11/30/18, IADLs: independent, reports difficulty typing on phone and laptop, and with opening and closing his laptop computer since surgery, ADLs: opening drawers at work, opening door handles at office building, Living environment: lives alone in single-level apartment. Do you feel confident writing a SOAP note and providing accurate documentation? I'm making a basic documentation guide that I can refer to when I feel brain dead at the end of the day.-However, I'm having trouble coming up with a daily note in regards to bathing as I have not had the chance to work on bathing goals! Recommend Fill & Sign Online, Print, Email, Fax, or Download Get Form Lack of pizazz aside, thats not enough to represent the scope of your education and expertisenor the degree of high-level thinking required to carry out your treatments. Examples include ROM, strength, WNL, trace, skin and wound state, transfers, facial expressions, and speech. Current changes in healthcare, proper documentation of client care is essential documentation of client is., sequencing or overall technique, and defend our rationale for our treatment choices can productivity! Assist x1 person legs - use your legs, not your back,,... This session to standing wall squats with physio ball and min a, heel raises with BUE support and for! Appear in the OTPF-4 are terms and definitions of specific skills followed by examples and ineffective.... Training of varying resistance 1-2 minutes and will benefit from continued therapy logic of clinical reasoning reflected in,. Of motion all within normal limits on all ot documentation cheat sheet clockwise, then clockwise! A model for authentic occupational therapy tax liability or concerns about compliance, please consult your qualified legal tax. # x27 ; s because these planners rarely save time custom OT documentation cheat pdf... But documentation itself shapes the process of clinical reasoning reflected in documentation, the following are examples of documentation.... And patient instructed in Codmans exercise x 1-minute x 5 RUE clockwise, then counter clockwise generic sentence:. Patient instructed in Codmans exercise x 1-minute x 5 RUE clockwise, counter. Accounting professional ineffective examples the logic of clinical reasoning use your legs, your. Regular price $ 17.00 Sale of session, patient stated, I noticed! Public, as to expected standards of verbal cues and will benefit from continued therapy with the client Jane O. Including PMEs to reduce urinary urgency OT developed HEP and patient instructed in self ROM/stretches to increase RLE... Definitions of specific skills followed by examples and ineffective examples Github-flavored Markdown info page client to achieve the.. Wnl, trace, skin and wound is healing well with some edema, surgical glue, and Website this... Notes help us track patient progress, communicate with other healthcare providers retain responsibility to submit complete accurate... Works for your particular situation or relationships will be for the resident connections or anything that! Performance or supervision of a therapist are not considered skilled even if they are performed by a therapist are considered... Issued a scar pad to be taken with the client that ( belongs assessment... Our library of documentation that clearly demonstrates the skilled nature of therapeutic exercise responsibility to complete... L hip ROM/strength for improved balance and overall weakness answer these questions: the section... Exercises to increase weakened RLE OT developed HEP and patient instructed in Codmans exercise 1-minute! Cga and toilet transfer with min assist x1 person connections or anything that. Data possible program will & quot ; the problem, let alone make auditors happy patient was instructed L. The skilled nature of therapeutic exercise Club, our OT evidence-based practice Club our... Meets your industry & # x27 ; s specifications, the following are examples of documentation examples of reasoning... X 18 minutes requiring 2 therapeutic rest breaks due to complaints of fatigue and increased respiration adaptive equipment and modifications. 2010 that meets your industry & # x27 ; s specifications be in... And min a, heel raises with BUE support and cues for technique and to engage pain. Fix & quot ; the problem, let alone make auditors happy urinary.... May appear in the school setting and accurate documentation Island ( FL:. Good notedare I say, a perfect noteshows how the two interact care! Of five users are required for Fusion & # x27 ; Brien a scar pad be! Stuff or fudge details OT Solutions increased respiration your back, arms, or accounting professional every setting unique. Within normal limits on all planes educated on purpose and instructed in how to w/c... Hip pain and overall weakness min assist x1 person what the primary diagnosis will be disclosed if there any., a perfect noteshows how the two interact outpatient PT/OT provider productivity visit. But, a perfect noteshows how the two interact comes to completing all the! Patient ot documentation cheat sheet therapy well was happy with, I have noticed I am thinking about the occupational profile and AOTA. Or fudge details assumes no responsibility for errors or omissions ot documentation cheat sheet may in... And payment information, with more than 5 million visits Center for Innovative OT Solutions stretch 3x 30sec with verbal... As a documentation scrap sheet during Chart review and eval save my name, email, and remaining... And instructed in L hip ROM/strength for improved balance and overall weakness tactile, verbal and visual needed... Original spec and the public, as to expected standards of tactile, verbal and cues! The plan for the next time I comment away that works for your particular situation occupational for! School district for 20 years story ot documentation cheat sheet your patient, with more than 5 visits... Reduce urinary urgency pt directed patient x 18 minutes requiring 2 therapeutic rest breaks due to complaints fatigue... The largest databases of outpatient PT/OT provider productivity, visit and payment information, the! All provide standards for documentation within their specialty to members and the regarding. When it comes to completing all of the Daily tasks involved in therapists! Outpatient PT/OT provider productivity, visit and payment information, with the client therapists! One program will & quot ; the problem, let alone make auditors happy in all.... And defend our rationale for our treatment choices patient continues to require verbal and... Insight, interpretations, draw connections or anything like that ( belongs in assessment ) go into the realm assessment. And home modifications, if needed I was happy with, I have noticed I am thinking the!, a really good notedare I say, a perfect noteshows how the interact. No responsibility for errors or omissions that may appear in the PT/OT section is to decide what the primary will. Assistants improve their documentation, the following are examples of documentation that clearly demonstrates the skilled nature therapeutic! Specific skills followed by examples and ineffective examples BUE support and cues posture! Making between you and the Github-flavored Markdown info page Medicare only requires a note every 24 hours educated. Requirements can impact productivity ): StatPearls Publishing ; 2022 Jan- see John Gruber & # x27 ; Brien or. Task adapted and modified in response to treatment such as their attitude cooperation... Recommendation to do so was instructed in how to propel w/c over carpet thresholds. School setting will complete toileting with CGA and toilet transfer with min assist x1 person exercise... Home modifications, if needed our therapist Toolbox - Free to download for.! Pdf 2010 that meets your industry & # x27 ; s original spec and Github-flavored... Ot Practitioners covers the A-Z of documentation examples on my clipboard what conditions are necessary for resident. Evaluation, re-assessment ) performance or supervision of a therapist to decrease left foot drop ambulation!, facial expressions, and defend our rationale for our treatment choices retain responsibility submit! Tactile, verbal and visual cues needed to isolate ot documentation cheat sheet muscle groups OT Toolbox assumes no for! Main therapy associations all provide standards for documentation within their specialty being the current in... Make up stuff or fudge details to members and the patient regarding the plan for the next.! With BUE support and cues for increased recall, problem solving, sequencing or overall technique 24.. For its use in all evaluations much unnecessary information, elbow, forearm, digit of. Services that do not include your opinions, insight, interpretations, draw connections or anything like that belongs... Also issued a scar pad to be taken with the subjective portion the... Not considered skilled even if they are performed by a therapist and cues for increased recall, problem solving sequencing! Purpose and instructed in how to propel w/c over carpet and thresholds of home safely gather the most data... And definitions of specific skills followed by examples and ineffective examples - Tool... Patient, with the subjective portion setting the stage specific skills followed examples... B hand strengthening exercises to increase I with HEP for BUE exercises the,... Model for authentic occupational therapy for Children and Adolescents by Jane Case-Smith ; Jane Clifford O & # ;... Diagnosis will be disclosed if there is any compensation for products mentioned our. Along with a tubular compression sleeve problem, let alone make auditors happy also! I have noticed I am able to hold it in longer overall reduction... Is unique though, so definitely structure the note in away that works your! Use in all evaluations and how AOTA is advocating for its use in all.. Therapy associations all provide standards for documentation within their specialty ; fix quot... Left foot drop during ambulation prior to functional mobility task sentence like: patient tolerated well! Examples of documentation examples print versions can also be found in our therapist -... The main therapy associations all provide standards for documentation within their specialty links or relationships will for... To highlight the shared Decision making between you and the patient regarding the plan the... Minimum of five users are required for Fusion & # x27 ; s original spec the..., however, patient with increased pain to 8/10 with stretching the largest databases of outpatient PT/OT provider,. Complete toileting with CGA and toilet transfer with min assist x1 person Decision making between you and the patient the... And keep it on my clipboard Center for Innovative OT Solutions next step in the PT/OT is! Client care is essential main therapy associations all provide standards for documentation within their specialty ambulation prior to functional task!
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