Documents patient care and results of treatment appropriately in the medical record to comply with policies and procedures of the department and regulatory agencies. Assists the Occupational Therapist with evaluation, directing, planning, and providing Occupational Therapy treatment for patients of all ages. Adheres to all unit-specific standards of care, clinical guidelines, and protocols in rendering patient care as described in department policies and procedures. Assists with assessments that are established by unit standards and addresses physical, social, and psychological needs of patient and family. Assessments are completed on all admissions and discharges. Assists with formulating plan of care based on identified patient problem areas in conjunction with the patient, family, and other health care team members. Administers treatments according to priority and department procedure. Evaluates effectiveness of therapy interventions and revises plan of care based upon patient response to interventions or because lack of progress. Coordinates and provides patient care, discharge planning, and patient and family education through initiation and participation in care conferences. Provides education and instructions to the patient and family specific to the patient's needs and individual treatment program. Thoroughly documents standardized assessments, reassessments, treatments, response to treatment, discharge summary, patient and family education in a timely and accurate manner. Provides for patient equipment and therapy needs when applicable after discharge. Makes patient assignments in collaboration with other team members. Directs and alters assignments in response to changes in patient situations. Utilizes patient and employee occurrence and incident reports. Interprets and follow policies and guidelines to define procedures and meet goals and deadlines. Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
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