Documentation: Outpatient vs Inpatient

One major difference I have noticed from spending time in both inpatient and outpatient pediatric settings this fall is the various methods of documentation that exist in the world of therapy.

At our hospital, we use a system called EPIC for online documentation.  Within this system, there are templates created for occupational therapy.  Each template is geared towards a population we may be treating.  For example, there is a pediatric template along with a NICU template.  These have been created to increase efficiency and ease of documentation.  The information within each template is relevant to the population you are treating.
I have been learning how different it is to document for the pediatric population, especially within the NICU.  I have been learning a whole new language to communicate through it seems! We are documenting what we gather from evaluations/assessments along with what treatments we provide and the rationale for our services.  Within the acute setting, another role we have is to determine the next level of care we feel is needed.  This may include going to an inpatient rehab facility to continue building strength and independence in ADLs, receiving outpatient services or even OT within the home.  We may also be suggesting adaptive equipment for the child and family to utilize at home to increase independence and safety, such as a commode or shower chair.  These are all pieces of information we include within our online documentation system.

The outpatient documentation that I have observed during this rotation has tended to be much more narrative form. It had been based off of a SOAP note format.  This means that there is a subject, objective, assessment, and plan portion of the note.  Goals are frequently revisited to document progress made.  Both settings take into account ADLs that are being addressed (if age appropriate) or developmental aspects that are requiring therapy.  In the outpatient setting, parents are typically very involved with the goals and home programs are crucial for progress to be evident.  As one therapist explained to me, there is only so much you can do in a 30-45 min session each week.  So much depends on the work that is done at home and involvement of the parents.  This is another reason why education is huge for parents so they truly understand what we are doing and how this can benefit their child.  If we explain ourselves and parents understand the strategies they use, they will often times feel more confident carrying through with home programs.

Being able to expand my skills set and broaden my documentation skills throughout this rotation has been great so far and I look forward to continuing to develop my skills!!

OT NICU Evaluation Form

The beginning of week 6 is upon us!  Time is flying and I am loving every bit of information I am learning in the NICU.

At the hospital I am completing my rotation at, when OT gets a consult from the medical team to evaluate and treat an infant in the NICU, we first complete a thorough chart review to gain as much information as we can before seeing the baby.  This is a way to be more prepared upon entering and determine what further information we need to gather throughout our session.

I have created a document that allows us to put all of our information in one place throughout the infant's hospital stay.  This evaluation form allows us to stay organized and best treat each baby and their families.  We also document all of our treatment sessions electronically.  This form is a way to keep up to date on our caseload and easily look for a baby's information within our clipboard or binder.

Name: Bay/Room # Date of Evaluation: GA: Reflexes: Palmar Grasp _______R   _______L Plantar Grasp _______R  _______L Scarf Sign __________	Mother’s Name: Age: Father’s Name: Age: Sibling______________Age__________ Sibling______________Age__________ Sibling______________Age__________ Sibling______________Age__________ Family Availability:
Infant Birth History DOB: GA at Birth: Mod of Delivery: Apgars________1min __________5min Birthweight _________g Diagnosis Complications of birth:	Maternal History Grava________ Para_______ Prenatal care/complications: Labor & Delivery: Medications:
Respiratory Assistance:	Social History:
Current Medications: Sedatives:  Diuretics: Anticonvulsants: Steroids: Antibiotics:  Other:  Caffeine      Theophylline	Interventions Provided: Stress Cues Observed:
Current Feeding/Nutrition: Time____________ Type__________	Coping Skills:   Observed      Facilitated Tone:
Head Shape Observations: Positioning devices provided/used:         Isolette    or    Crib

Outpatient Pediatric Therapy

Along with my time spent in the hospital, I am also fortunate enough to get some experience in a pediatric outpatient setting as well.  Each week I have been spending a day at a pediatric clinic.  I have really enjoyed this opportunity.  I definitely have to think in a whole different way!  The documentation is very different, along with the focus for the children.

In the outpatient world, an occupational therapist may be helping a child increase their fine motor strength and coordination so they can hold their pencil properly at school all day.  A child may be having a hard time dressing themselves or completing other age appropriate self care tasks and that may be one of our goals.  We may work on strengthening various muscles through play and exercises.  They may be struggling with processing all of the sensory input they are receiving and react in frustration and negative behaviors.  As therapists, we could help kids and their parents develop appropriate coping mechanisms and increase their tolerance to various sensory stimuli that their brain previously could not handle.  A child may be having a hard time planning the actions they want to perform or being attentive to a task at hand.  

We may treat children with a diagnosis such as cerebral palsy, down syndrome, autism, developmental delay, anxiety, and so many more.

A lot of kids I have seen have been working on handwriting.  Many of the therapists are either trained in handwriting without tears or use some of their techniques within their treatment sessions.  This is a well known curriculum many teachers use when teaching children to write.

For more information on handwriting without tears and their handwriting strategies visit:

https://www.hwtears.com/hwt

Another important aspect of outpatient pediatric therapy is the occupation of play.  If the child is motivated and excited to participate in therapy, they will not view what they are doing as work but rather a time to play and have fun.  This depends on the age of the child of course, but if a child feels they are simply playing with some of their favorite toys, they can improve desired skills without realizing they are working for it.  Children learn so well through exploration during play and appropriate supports in place. 

                                                                        Retrieved From: http://www.spotstx.com/about/

An additional component of any outpatient therapy is what is done outside of therapy.  As therapists, we cannot fully help a child if they are only working on their goals during one session each week.  It is important to educate parents and children (as appropriate) on what they need to continue working on at home.  We want to make sure parents feel comfortable completing their home program.  We all understand that life gets busy and some weeks are better than others, but with continued work at home, the child can best succeed at meeting their goals.

I look forward to gaining more outpatient experience and will continue to share them with you! 

Premature Infant Occupations

What occupations are important for a premature infant?

I am already in the 4^th week of my rotation!  Time is flying and I am learning so much.  I feel like I am a sponge trying to soak as much up as I can.  As a future occupational therapist spending time in the NICU, it is only natural to think about our role within this setting and what occupations are important and meaningful for the infants we are treating.

Just as we would not expect each adult or child to value the same occupations, the same holds true for a premature infant and their family.  Each baby and their family must be treated individually and holistically. 

An occupation within the NICU that therapists are commonly addressing is an infant’s ability to explore.  Even though premature infants spend much of their time sleeping (which is very important for development and growth) the small amount of time spent awake is crucial for the wiring of their brain.  During that time, infants have the opportunity to explore their environment.  Exploration, specifically sensory exploration, is an occupation that will shape the infants cognitive development.  The way an infant experiences touch, movement, oral sensations, sound, and visual stimuli are all shaping the way their brain develops.

Within this post, I want to focus on the important of touch. Our tactile system is the  most developed at birth.  It is the foundation of all experiences and contributes greatly to future emotional and intellectual development.  Within the womb, the infant is continuously receiving tactile input that is comforting and soothing.  When that child is born early, the input quickly changes.  Medically, the baby is experiencing unpleasurable events related to their necessary medical cares.  These events can have lasting effects on their sensory development and the way they perceive their environment.  For example, when a baby is receiving painful heel sticks or an IV placement, the brain is learning that touch is negative and something they want to avoid.  An infant who has developed an aversion or hypersensitivity to touch may:

•           Demonstrate developmental delays
•           Experience difficulty bonding with parents
•           Develop issues with feeding later in life

This is why it is so important for families to understand the importance of positive touch and provide these opportunities so when they go home and continue to grow, they do not develop an adverse reaction to the tactile stimulation they will encounter during their daily activities. 

Positive touch helps parents connect and bond with their baby and enables the infant to learn all touch is not bad.  The purpose of positive touch is to:

•           “Buffer” the necessary but sometimes unpleasant experiences in the NICU
•          Empower parents to take control over caring for their baby in this setting
•           Increase the baby’s positive sensory experiences
•          Limit the negative effects that stress of the NICU has on development
•           Prevent your baby from being sensitive to certain touch experiences

There are multiple ways positive touch can be administered:

•           Providing skin-to-skin or Kangaroo Care
•           Providing gentle, firm pressure to areas of the body that have experienced any negative touch (commonly feet, mouth and face area)
•           Watch your baby’s cues to help you know if he/she is tolerating the positive touch
•           Perform appropriate infant massage techniques taught to the parents

It is important to provide positive touch experiences 1-2 times per day or anytime there is interaction with the baby to support their growth and development.

What is Occupational Therapy?

As this rotation begins to take off, I wanted to make sure that I provided a further description as to what occupational therapy is and more specifically how occupational therapists work with children. 

When I began my OT program at Creighton, I was often asked, “What exactly is occupational therapy?”  Learning how to explain the profession without confusing people took some practice.  The beauty of our profession is that it can wear many hats.  That can also make it hard to explain to someone.

An occupational therapist is someone who specializes in working with individuals who are experiencing a condition that is limiting their ability to independently complete the tasks of everyday living.  For example, after an individual has a stroke, they may have a hard time using their body the same way they did prior.  Their brain may also think differently than it had before the stroke.  Things such as getting dressed, bathing, or eating a meal may be very hard for them to complete.  Part of our profession, is to help retrain the brain and regain as much function as possible.  We may also modify their environment to ensure they can safely participate in their daily activities.

In pediatrics, occupational therapists use their expertise to help children gain the functional skills they need for independence in play, learning, motor skill development, self-care, and socialization in their home, school, and community environments.  Environmental modification and adaptation is another key component we may use to assist the child in successfully participating in valued occupations.  Occupational therapy strives to ensure treatments and goals are client-centered to meet the needs of the child and their family.

An occupational therapist is able to use their knowledge and creativity to assist each patient reach the goals they find meaningful.  Being able to become part of a profession that values the needs of others so greatly is something I cannot wait to be a part of!