I am a COTA and have just started working at a nursing home after 11 years in a hospital setting and am very unclear on the rules for documentation in the long term care setting.  I am pretty sure I can do the progress notes, but what about the recertifications and discharge notes?  From reading in older text books, it appears that I am not able to write new goals, but on these forms you are actually only updating current goals. 

Any help/guidance would be appreciated and is there a website to look these things up on??

Thanks!

I would check with your state regulations.  I have always worked in LTC in the midwest and COTA's are allowed to add new goals and upgrade goals through out the treatment.  However on Med A's the recertifications have to be done by the OTR.  I am also able to D/C a patient and write that note, but the OT has to sign off on it (FYI -- The OT must co-sign all notes and restorative programs you set up) Med B's are a different story...you must keep track of your visits with each patient; the OTR is required to treat each patient on their 10th visit and write a note on them and still do a recertification when it is needed.  I hope this helps!