Organization and

Administration for
occupational therapy
Done by: yogalakshmi. M
211701003
B.O.T Final year
Define record. Write its purposes. Explain
the different types of records with
examples. How records should be
maintained?
Record:
A Record is a written account of factors
events which may be kept for current or future reference.
Purpose of records:
Records are kept for the legal protection of
patients and personnel, to provide a written account of
the patient progress, to give information about and
confirmation of medical orders and to supply information
from which to evaluate the progress of the department as
a whole.
Types of records
Two categories of information need to be recorded:
Medical
Administrative
Medical information is maintained primarily for the benefits
of the patient. Through the careful recording of every
pertinent detail of medical management a better treatment
program can be carried out.
Administrative information deals with policies and
operational procedures of the department.
Medical Records

 Referral froms
 Progress notes
 Special tests and measurements
 Attendance
 Home instructions
 Discharge note
Administrative Records

 Attendance
 Equipment and supplies
 Inventories
 Budgets
Charges
 Maintenance and repair records
 Personal records
 Loan service records
 Accident
Medical Records:
REFERRAL FROMS:
Since misrepresentation or distortion is
always possible in transmitting information orally, written
orders are essential and provide a permanent record.
Desirable information on the referral from is
the date of referral agency or service, case or chart
number, patients name, address.
Progress notes:
Progress notes are based on specific
observations which are recorded in a factual,concise and
explicit manner. Progress notes must be a dated and
signed by the physician or therapist.
Special tests and measurements:
Forms specifically designed to facilitate
recording and interpreting results of tests and
measurements should be maintained and made available
to appropriate personnel
Among the most common forms are those used to
record manual muscle tests, goniometry, activities of
daily living, physical evaluations, and work evaluations
Attendance:
It's is of medical significance to physicians to
know the regularity. Frequency and duration of patients
treatments. Attendance of individual patients is recorded
and the total number of treatments indicated periodically
on the patients record.
Home instructions:
Frequently the treatment program is
augmented by activities carried out in home. Specific
instructions should be given to the patient and/or his
family for activities be carried out during weekend visits
at home, between scheduled clinic visits or following
discharge from the active treatment program.
Discharge note:
At the time of discharge, a final patient
evaluation should be made and recorded with a brief
summary of program and results of treatment. Reasons
should be started for the termination of treatment.
Administrative Records:
Attendance:
In addition to the medical purpose of attendance
records, administration has need for an accurate accounting
of individual patients treated in various programs.
This information can be used for an accurate
accounting of individual patients treated in various
programs. This information can be used to justify additional
staff, additional equipment and supplies and space request
and it can help determine fees and billing.
Equipment and supplies:
The procurement of supplies and equipment
involves either three or four stages of recording. The
requisition should provide information in regard to a
description of the item (size,quality, type, color and other
identifying characteristics)
When supplies are received, the receiving agent
, should make out a receiving report. Which indicates
specifically what was received and in what quantity. The
information should be tailed with the purchase order.
Inventories:
The concerned therapist should maintain a
working record of supplies and equipment. A simple card
file usually suffices, with each item entered on separate
card.
The recording of units issued and balance on
hand makes an efficient method for maintaining a
perceptual inventory. These card will provide necessary
information for budgeting and cost accounting.
Budgets:
The preparation of a hospital budget require
the combined cooperative efforts of department heads,
accounting and business office, and the administrative
staff.
Types of budgets generally include the
operating budget, the cash Budget and the capital
expenditure budget.
(1) Operating budget: The operating budget is made
up of the combined department income and expense
budgets. It is estimated on the basis of experience
provided by the past and current years budgets
(2) Cash Budget: The cash budget is an accounting
of the amount of cash available for payment of salaries
supplies, expenses and capital expenditure. It is
prepared on a month-by-month basis.
(3) Capital expenditure budget:
The capital expenditure budget
contains an estimate of funds to be expended for
equipment and buildings. It permits planned expenditure
to be made over a period of time for equipment, buildings
and major building repairs.
Charges:
The record form used in the billing of services
to patients is called a charge slip. The form needs to
include only the essential information such as
department identification. Patient's name and location
dates and unit of service and charges. It should be
signed by an authorized representative of the
department.
Maintenance and repair records:
Equipment requiring regular maintenance, such as
typewriters and machines which need to be picked periodically,
should have a record indicating the date on which it was last
checked.
In some situations, the repair will be handled within
the treatment facility but in others, the ordersay go to an outside
firm or be handled through a servicing contract. In any case,
information pertaining to the repairs should be entered on the
maintenance card for the particular piece of equipment.
Personnel records:
Official records on occupational therapy personnel
may be the responsibility of the personnel department of the
organization; however the occupational therapy administrator
should maintain a file on each member of the occupational
therapy staff,paid, student and volunteer. In addition to name,
current address, telephone number and emergency notification
data.
Other information like; special interest and skills date of
employment, prior experience etc..
Loan service records:
Books, magazine and equipment are often available
through the occupational therapy department for loan to
patients or for use by staff members or students. Frequently
rehabilitation literature or craft manuals are included.
The department should have some system through
which an accurate record is kept showing who has each
piece of material, date loaned, date due and date returned.
Accidents and emergency records:
Accidents and emergencies must be reported
immediately to the proper authorities and a written report placed
on file. The organization standard procedure for reporting details
should be followed.
The supervisor should be very strict in reporting all
accidents and insist upon full cooperation from the person
injured, no matter how minor the accident, if the accident
involves a patient, an entry of facts should be made in the
progress records and filled in the patients chart.
Maintenance of records:
The development, maintenance, and revision of
records for a department require careful planning. Every
record must full fill a purpose that is clearly defined. The
purpose that is clearly defined. The purpose determines
what information is to be secured.
How it is to be recorded, who is to recorded it, and
by whom it is to be used. The following may help I'm
developing an efficient record system.
1. The records of an occupational therapy department
should meet the standards of the facility. Records may be
developed with the assistance of the medical records
librarian, but all official records should have
administrative approval
2. Records should be designed so that only minimal
clerical work will be required for their maintenance.
3. The following identification should be on the top of
every record. “ Occupational therapy department”, name
of institutions, city and state, a little indicative of the
purpose of the record and date used.
4. The date of publication of the form should be indicated,
usually in lower corner. In case of revision, the date of
such revision should be included.
5. Different colored stock may be used for different forms
6. Those forms that can be sent to other clinics, when a
patient is transferred, should be printed on material that
is of a size and weight suitable for mailing
7. Those forms that can be sent to other clinics , when a
patient is transferred, should be printed on material that
is of a size and weight suitable for mailing.