OT-RehabEd-Write it Right: Ethically Responsible Documentation

This continuing education program aims to enhance therapists’ knowledge and application of legal, professional, and organizational ethics for documentation and charging practices in the inpatient and outpatient hospital settings. Education is oriented explicitly to occupational, physical, and speech-language therapists.

Rehabilitation therapists will be educated on the key legal compliance requirements impacting documentation within the legal medical record. Regulatory guidelines will be incorporated from the Centers for Medicare and Medicaid Services (CMS), the Health Insurance Portability and Accountability Act (HIPAA), the Joint Commission (TJC), and third-party payers.

 Key ethical compliance requirements impacting therapist practice and documentation within the legal medical record will be integrated. Ethical expectations will be reviewed from professional associations, including the American Occupational Therapy Association (AOTA), American Physical Therapy Association (APTA),  American Speech and Language Association (ASHA), the Ohio Administrative Code, and the Ohio Health Code of Conduct.

 Defensible documentation expectations will be identified, including the Center for Medicare and Medicaid Services (CMS) requirements for supporting evaluation complexity codes, justifying skilled intervention, and establishing medical necessity within the plan of care. The necessity for recording treatment time and timely documentation will be emphasized. Applying the outpatient billing rules, including the eight-minute charging rule to outpatients in hospital beds, will be reviewed for charging clarification.

 Therapists will also be educated to quality improvement opportunities resulting from therapists’ chart audits. The safety impact of timely and effective documentation on clinical practice will be highlighted to support high-performing organizational (HRO) goals.

In summary, incorporating an ethical focus and professional integrity into documentation and charging practices is essential in clinical practice. The program aims to enhance therapists' professional and ethical acumen in therapeutic documentation.

1. Therapists will be educated on the key legal compliance requirements impacting occupational therapists/assistants, physical therapists/assistants, and speech language pathologists' documentation within the legal medical record.
2. Therapists will be educated on the key ethical requirements impacting occupational therapists/assistants, physical therapists/assistants, and speech language pathologists' documentation within the legal medical record.
3. Therapists will be educated on defensible documentation requirements for the most frequently identified chart audit opportunities.
4. Therapists will be educated on assessment requirements that support evaluation complexity codes, skilled intervention, and medical necessity in the plan of care, as well as documentation timeliness.
5. Therapists will be educated to identify chart audit improvement opportunities.

This event is approved for 1 CEU by the Ohio OTPTAT Board - OT Section.