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Documenting Caregiver Training

Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS

December 16, 2015

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Question

How should therapists correctly document caregiver training?

Answer

·      Document the instruction provided to the patient and supportive personnel

o   Who is being taught?

o   How is the teaching conducted?

o   When is the teaching conducted?

o   Who does the teaching?

o   What is the duration of the instruction?

o   Why is the instruction necessary?

I see in the documentation frequently “educated staff regarding transfers” or “educated staff to patient safety during gait.”  That does not say a whole lot.  When we do that documentation, who is being taught?  Is it the patient, the caregiver, or the staff?  How is the teaching conducted?  Is it hands-on teaching?  Is it in lecture?  Is it a handout or webinar?  When is it being conducted?  Is it during the day? During daylight shift?  In the evening, perhaps while the patient may be sundowning?  Who is doing the teaching?  Is it you?  Is it an assistant who works with you?  Is there a team of you?  OT and PT working together to do teaching and training?  How long have you done the instruction?  Why is it necessary?  Why do you want this person to learn this?  Most importantly, what is their return demonstration?  I can say that I trained this person related to safety, transfers, and correct hand placement during the transfer.  I also want to follow up that that caregiver is able to return demonstrate 50% of the time.  If the caregiver is the spouse and I am discharging that patient to home to live with said spouse, and caregiver is only 50% return demonstrating or compliant, I need to keep them on caseload.  I think when you add that level of detail, it lends credibility to that medical necessity and why you may continue to treat them. 


kathleen d weissberg

Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, CFPS

In her 30+ years of practice, Dr. Kathleen Weissberg has worked in rehabilitation and long-term care as an executive, researcher, and educator.  She has established numerous programs in nursing facilities; authored peer-reviewed publications on topics such as low vision, dementia quality care, and wellness; and has spoken at national and international conferences. She provides continuing education support to over 40,000 individuals nationwide as National Director of Education for Select Rehabilitation. She is a Certified Dementia Care Practitioner, a Certified Montessori Dementia Care Practitioner, and a Certified Fall Prevention Specialist.  She serves as the Region 1 Director for the American Occupational Therapy Association Political Action Committee and adjunct professor at Gannon University in Erie, PA. 


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Course: #3072Level: Intermediate1 Hour
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PTs can apply evidence-based interventions to improve dementia care. This session reviews the etiology of common behaviors. Cognitive-emotion, multi-sensory, animal-assisted, and exercise interventions to reduce agitation are discussed as well as specific strategies for improving task-related engagement. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

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Course: #4377Level: Intermediate2 Hours
  'her examples, delineation between Mcr A and Mcr B pts/treatments'   Read Reviews
This presentation reviews the definitions of supervision as well as APTA guidance related to supervising assistants, students, and aides in various healthcare environments. Documentation guidelines for Medicare are reviewed as these relate to what an assistant can complete versus a therapist. The use of students and rehab aides in long-term care is reviewed in accordance with Medicare guidelines. Real examples of common supervisory ethical dilemmas from the field, including the appropriate action steps to take in each one, are highlighted. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA

Dementia Management: Techniques for Staging and Intervention
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Course: #3649Level: Intermediate2 Hours
  'very informative and slides were easy understand'   Read Reviews
This seminar provides an overview of types of dementia including characteristics at each stage, protocols for staging clients with dementia and related treatment strategies. Documentation and treatment planning based on dementia staging results is reviewed. Behavior management and communication strategies for this population are discussed as well as techniques for nursing to follow. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Bullying Among Older Adults: Not Just a Playground Problem
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In this session, participants learn the definition and incidence of bullying in adult living communities and day centers, including what older adult bullying looks like in this population. Characteristics of older adult bullies, as well as their targets and gender differences, are explored. The reasons why bullying occurs, as well as the five different types of bullies, are defined. Interventions for the organization, the bully, and the target are reviewed to help communities minimize (and prevent, where possible) bullying and mitigate the effects on the target. Addressing bullying behavior among older adults is critically important for enhancing the quality of life and promoting emotional well-being; strategies to create caring and empathic communities for all residents and staff members are reviewed.

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