Clinical Reasoning and Documentation with Ben
This learning activity is designed to improve clinical reasoning and documentation skills in an acute care setting for a client with a neurologic impairment.
By the end of this learning activity, the successful student will:
Utilize therapeutic use of self to encourage engagement despite pain or frustration.
Promote attention to the affected upper extremity during functional tasks.
Modify the task, environment, and levels of assist to promote the just-right-challenge with emphasis on safety and participation.
Document an occupational therapy treatment note, including billing code(s), levels of assist, cognitive status, discharge recommendations, and updates to the plan of care as necessary.
Related ACOTE Standards (2023):
B.2.7. Activity Analysis
B.3.6. Provide Interventions and Procedures
B.3.8. Grade and Adapt Processes or Environments
B.4.3. Documentation of Services
Related ICE Videos
Self-Care: Dressing in Acute Care, Part 1 (4:43 min)
Self-Care: Dressing in Acute Care, Part 2 (4:21 min)
Self-Care, Part 1: Oral Hygiene at the Sink in Acute Care (2:15 min)
Self-Care, Part 2: Washing at the Sink in Acute Care (4:11 min)
Self-Care, Part 3: Brushing Hair at the Sink in Acute Care (2:05 min)
Mobility: Transfer and Bed Mobility in Acute Care (2:26 min)