O ccupational therapy has certainly seen the full spectrum when considering the focus in documenting our services. Emphasis has swung dramatically between use of clinical terminology vs. a purely layman's interpretation. Fortunately, we now appear to be landing on some comfortable middle ground.
Documentation remains our primary link in seeking reimbursement from our intermediaries.
Unfortunately, the opportunity to otherwise detail a plan of care does not often present itself until after a denial of services. Knowing this, it behooves each clinician to be clear and concise when completing paperwork. Third party payor sources' expectations for skilled therapy have remained fairly constant over the past decade. This expectation is more than justified.