Occupational Therapy EMR (OT EMR)
Documentation done as a peer‑level discussion, not grunt work. The chart‑native A.I. keeps clinical decisions clear and outcomes tied to ADLs/IADLs—so programs are reproducible, safe, and defensible.
How OT sessions flow in PBS EMR
- Prep: safety lines & secondary precautions surface first; prior outcomes and plateaus in view.
- Session: ADLs, caregiver coaching, vestibular moments inside tasks, hand/UE work, cognition & energy budgeting.
- Note: AI drafts SOAP with citations; flowsheets update weekly for reproducible care; you accept/edit/ignore.
ADL‑based flowsheets & outcomes
Dexterity, bilateral use, balance, pain, ROM/strength, cognition, ADLs/IADLs—measures link back to interventions so plateaus are obvious and progress is defensible.
Neuro & hand/upper extremity
- Task‑oriented training, CIMT principles, grasp/release progressions, edema & scar management, protective sensation, orthoses notes.
- Objective tracking (ROM/MMT, grip/pinch dynamometry, 9‑Hole Peg, Box & Blocks) tied to function.
Pediatrics & school collaboration
- Play‑based goals mapped to ADLs (feeding, dressing, hygiene), handwriting/visual‑motor, classroom accommodations.
- Caregiver/teacher handoffs and IEP‑friendly summaries for carryover.
Sensory integration & regulation
- Modulation profiles, environmental supports, and graded exposure; regulation strategies embedded in task sequences.
- Safety cues and stop criteria keep sensory diets reproducible across staff.
Cognition, perception & vision
- Attention, memory, executive function, neglect, visual fields/oculomotor; task breakdown and environmental mods documented.
- Return‑to‑learn/work notes with accommodations and measurable targets.
Seating, mobility & assistive tech
- Trials with seating, mobility aids, switch access and mounting; AT recommendations with training and caregiver education.
- Vendor/MD coordination recorded for a clean audit trail.
Home, IADLs & community
- Meal prep, medication, budgeting, community navigation, public transit; home eval checklists with risk & priority flags.
- Care team notes keep goals aligned across settings.
Work rehab & ergonomics
- Job demands analysis, graded work simulation, ergonomic coaching; durable, reproducible recommendations for HR/MD.
Delegation & compliance
Technician‑ready steps with guardrails (sets/reps/load, inclusion cues, stop criteria) make complex sessions consistent across clinicians and sites—ideal for scaling without losing nuance. Audit‑aware language is baked in.
Practice management that speeds cash
- Scheduling: evals, orthosis checks, caregiver training slots—right from the chart.
- Eligibility & authorizations: verify benefits, visit limits, and expirations in‑chart.
- Billing: claim scrubber and direct‑to‑payer routing where supported, with ERA auto‑posting for fast reconciliation.
- Payments: accurate patient responsibility, statements, and secure links.
Education only; protocols and payer rules vary. Follow orders, clinic policy, and current safety guidelines.
Related
Physical Therapy EMR ·
Speech Therapy EMR ·
Pediatric Therapy EMR ·
Hand Therapy EMR ·
Vestibular & Concussion EMR
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Occupational Therapy EMR — FAQ
Does the AI replace clinical judgment?
No. It reads and cites the chart, flags gaps, and proposes options with inclusion cues and stop criteria. You accept, edit, or ignore.
How are the flowsheets different for OT?
They open with a concise safety line and surface secondary precautions when relevant. Activities are grouped by ADL/IADL domains and room/equipment flow with a short wrap‑up to free provider time.
Which OT settings are supported?
Outpatient neuro/hand/UE, pediatrics, geriatrics/falls, vestibular, and community/home. Flows and dashboards adapt per setting.
Is it HIPAA‑conscious and audit‑aware?
Yes. HIPAA‑conscious workflows, audit‑aware phrasing, scrubber checks, and optimized routing/ERA reduce friction and keep documentation defensible.