An important aspect of patient care as an occupational therapist in a skilled nursing/long-term care (SNF/LTC) facility is completing thorough documentation of services provided.Completion of documentation in this setting can be overwhelming and time consuming but it doesn’t have to be. Documentation for Skilled Nursing & Long-Term Care: A Guide for Occupational Therapists presents an overview of standard documentation in this setting from initial evaluation to the discharge of OT services.This book will discuss the necessary components for quality documentation of OT services including: Initial OT evaluation and establishment of the OT plan of care Functional and measurable goals Section GG of The Minimum Data Set (MDS) Daily treatment notes and billing Weekly progress notes, 10th visit notes, insurance updates Updated OT plan of care/recertification Discharge Summary Group, concurrent & co-treatments Point of service documentation & productivity OT screensDocumentation for Skilled Nursing & Long-Term Care: A Guide for Occupational Therapists is intended to educate the following: An OT student starting Level II fieldwork in a SNF/LTC facility A new graduate OT entering employment in a SNF/LTC facility An experienced OT transitioning to SNF/LTC from a school based or mental health setting An OT working in SNF/LTC who strives to improve their clinical documentation skills This book is meant to be a resource to guide clinical documentation. After reading this book, you will be more confident in documenting the OT services you provide from the start of care to the discharge of OT services. About the AuthorAmy M. Colon, OTR/L is a practicing occupational therapist in a skilled nursing/long-term care facility in Maine. Amy graduated from The University of Southern Maine in 2001 with a Bachelor of Arts in Natural and Applied Science and Master of Arts in Occupational Therapy in 2004. Amy enjoys spending time with her family and reading a good book sitting in the sun.
