2.2 Chart Review, Interprofessional Collaboration & Precautions
Key Takeaways
- Systematic chart review prior to direct client contact is a fundamental safety mandate for the COTA to verify physician orders, activity clearance, weight-bearing status, past medical history, and current precautions.
- Vital sign monitoring (blood pressure, heart rate, respiratory rate, SpO2) and laboratory value interpretation (Hemoglobin, Hematocrit, Platelets, INR, Potassium, Blood Glucose, Troponin) dictate whether therapy must be modified, adapted for energy conservation, or withheld entirely.
- Interprofessional collaboration requires clear role delineation among team members (OTR/COTA, PT/PTA, SLP, RN, MD/DO, MSW/Case Manager) and structured communication using the SBAR framework (Situation, Background, Assessment, Recommendation).
- Clinical precautions—including sternal precautions post-cardiac surgery, spinal precautions (BLT: No Bending, Lifting > 5-10 lbs, Twisting), weight-bearing restrictions, and DVT/PE red flags—must be integrated into every occupational therapy intervention.
Last updated: August 2026
Chart Review, Interprofessional Collaboration & Precautions
Before initiating any direct client contact or therapeutic intervention, the Certified Occupational Therapy Assistant (COTA) must conduct a thorough, systematic chart review. In modern clinical environments, this occurs via the Electronic Health Record (EHR).
Reviewing the medical record allows the COTA to identify active physician orders, clarify weight-bearing status, verify medical stability, evaluate diagnostic lab panels, monitor vital sign trends, and recognize mandatory clinical precautions. Interprofessional teamwork and clear, standardized communication ensure client safety across acute care, inpatient rehabilitation, skilled nursing, and home health settings.
1. Systematic EHR Chart Review Protocol
A structured chart review protocol prevents oversights and ensures that no critical safety contraindication is missed before entering the client's room.
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| SYSTEMATIC CHART REVIEW SEQUENCE |
| |
| [1. ACTIVE ORDERS] ---> Verify OT order, frequency, activity |
| level, diet, & weight-bearing status. |
| | |
| v |
| [2. HPI & PMH] ---> History of Present Illness, onset date, |
| surgical procedure, comorbidities. |
| | |
| v |
| [3. NURSING & MD NOTES] ---> Overnight events, behavioral changes, |
| pain control, line placements. |
| | |
| v |
| [4. VITALS & LAB VALUES] ---> 24-hr vitals trends, CBC, Coagulation, |
| Electrolytes, Cardiac markers. |
| | |
| v |
| [5. INTERPROFESSIONAL] ---> PT mobility status, SLP dysphagia diet, |
| MSW discharge disposition plans. |
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Essential Chart Elements for the COTA:
- Physician Orders: Confirm that occupational therapy is actively ordered, check for specific activity restrictions (e.g., "Bed rest until cleared", "Out of bed to chair with assist"), and verify weight-bearing or movement limits.
- History of Present Illness (HPI): Understand the exact mechanism of injury, surgical interventions, and acute hospital course.
- Past Medical History (PMH): Identify chronic co-morbidities that influence activity tolerance (e.g., COPD, CHF, diabetes, renal failure, prior stroke, osteoporosis).
- Lines, Tubes, and Drains: Note the presence of IV lines, central venous catheters, arterial lines, Foley catheters, chest tubes, or surgical wound drains.
2. Vital Signs: Normal Ranges & Hemodynamic Red Flags
Monitoring vital signs before, during, and after occupational therapy interventions provides immediate objective data on cardiopulmonary response and physiological tolerance.
| Vital Sign | Normal Adult Range | Exercise / Activity Response | Red-Flag / Stop-Therapy Parameters |
|---|---|---|---|
| Blood Pressure (BP) | Systolic: $90–120\text{ mmHg}$<br>Diastolic: $60–80\text{ mmHg}$ | Systolic BP gradually increases with physical workload ($8–12\text{ mmHg}$ per MET); Diastolic remains relatively stable ($\pm 10\text{ mmHg}$). | • Hypertensive Crisis: Systolic $>180\text{ mmHg}$ or Diastolic $>110–120\text{ mmHg}$.<br>• Hypotension: Systolic $<90\text{ mmHg}$.<br>• Abnormal Drop: Drop in Systolic $>10–20\text{ mmHg}$ with increasing workload. |
| Heart Rate (HR) | $60–100\text{ bpm}$ (Resting) | Increases proportionally with exercise intensity. Target HR calculated based on age and cardiac history. | • Resting Tachycardia: $>100–120\text{ bpm}$ at rest.<br>• Resting Bradycardia: $<60\text{ bpm}$ (unless conditioned athlete).<br>• Sudden Drop: Drop in HR $>10–20\text{ bpm}$ during activity.<br>• Irregular rhythm / new onset atrial fibrillation. |
| Respiratory Rate (RR) | $12–20\text{ breaths/min}$ | Increases smoothly with exertion to meet metabolic oxygen demand. | • Tachypnea: $>24–30\text{ breaths/min}$ at rest.<br>• Bradypnea: $<10\text{ breaths/min}$.<br>• Severe dyspnea, cyanosis, accessory muscle use, intercostal retractions. |
| Oxygen Saturation ($SpO_2$) | $95–100%$ on room air | Should remain $\ge 90–92%$ during moderate activity. | • Desaturation: $<90%$ in general adults ($<88%$ in clients with chronic COPD / pulmonary fibrosis).<br>• Titrate supplemental $O_2$ only per active physician order. |
Orthostatic Hypotension Protocol
Orthostatic Hypotension is a common and dangerous drop in blood pressure triggered by transitioning from supine to sitting or standing postures (frequently caused by prolonged bed rest, dehydration, antihypertensive medications, or autonomic neuropathy).
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| ORTHOSTATIC HYPOTENSION: CRITERIA & ACTION |
| |
| [DIAGNOSTIC CRITERIA] |
| Within 3 minutes of standing or upright sitting: |
| • Drop in Systolic BP >= 20 mmHg OR |
| • Drop in Diastolic BP >= 10 mmHg |
| • Accompanied by dizziness, lightheadedness, pallor, or diaphoresis. |
| | |
| v |
| [IMMEDIATE COTA MANAGEMENT PROTOCOL] |
| 1. Immediately recline the client or assist back to supine / seated. |
| 2. Elevate lower extremities to facilitate venous return to heart. |
| 3. Monitor vital signs until stabilized; recheck BP. |
| 4. Apply compression stockings / abdominal binder if ordered. |
| 5. Notify nursing staff and document the orthostatic episode. |
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3. Critical Laboratory Values & Clinical Activity Thresholds
Routine blood panels provide insight into hematologic status, coagulation, electrolyte balance, and organ function. The COTA must evaluate whether laboratory abnormalities warrant modifying therapy intensity or holding treatment altogether.
Complete Blood Count (CBC) & Coagulation Panel Guidelines
| Laboratory Test | Normal Reference Range | Clinical Significance | Activity Modification & Hold Thresholds |
|---|---|---|---|
| Hemoglobin (Hgb) | Males: $14.0–17.5\text{ g/dL}$<br>Females: $12.3–15.3\text{ g/dL}$ | Oxygen-carrying capacity of red blood cells. Low levels cause fatigue, dizziness, and ischemia. | • $<8.0\text{ g/dL}$: Severe anemia. High risk of syncope. Hold aggressive exercise; limit to light bed mobility, essential seated self-care, or hold per facility policy.<br>• $8.0–10.0\text{ g/dL}$: Light seated ADLs, frequent rest breaks, monitor vitals.<br>• $>10.0\text{ g/dL}$: Resistive exercise and standard functional mobility as tolerated. |
| Hematocrit (Hct) | Males: $41–50%$<br>Females: $36–44%$ | Percentage of total blood volume made up by RBCs. | • $<24%$: Hold resistive exercise; light ADLs only; monitor for dyspnea.<br>• $24–30%$: Light functional activity with energy conservation. |
| Platelets (Plt) | $150,000–400,000/\mu\text{L}$ | Blood clotting and hemostasis. Thrombocytopenia creates spontaneous bleeding risk. | • $<20,000/\mu\text{L}$: Extreme Bleeding Risk. Spontaneous hemorrhage hazard. Defer resistive exercise; gentle bed ADLs only; avoid tooth brushing with stiff bristles; strict fall prevention.<br>• $20,000–50,000/\mu\text{L}$: Light ADLs, gentle AROM, no resistive weights or intense friction.<br>• $>50,000/\mu\text{L}$: Progressive resistive exercise and full functional activities. |
| International Normalized Ratio (INR) | Normal: $0.8–1.2$<br>Therapeutic (Anticoagulated): $2.0–3.0$ | Standardized measure of blood clotting time for clients on Warfarin (Coumadin). | • $>3.5–4.0$: High risk of internal bleeding or joint hematoma. Avoid resistive exercises, aggressive manual therapy, and high-fall-risk mobility tasks.<br>• $>5.0$: Critical Medical Alert. Client on strict bed rest; hold therapy until medically corrected. |
| White Blood Cells (WBC) | $4,500–11,000/\mu\text{L}$ | Immune defense. Elevation indicates infection; depression indicates neutropenia. | • $<1,000/\mu\text{L}$ (Neutropenia): Client at severe risk of life-threatening infection. Follow Neutropenic Isolation Precautions (wear clean mask, strict hand sanitizing, sanitize all therapy equipment before use). |
| Potassium ($K^+$) | $3.5–5.0\text{ mEq/L}$ | Critical for cardiac conduction and neuromuscular excitability. | • $<3.5\text{ mEq/L}$ (Hypokalemia) or $>5.0\text{ mEq/L}$ (Hyperkalemia): High risk of fatal cardiac arrhythmias. Consult RN/MD before therapy; monitor ECG telemetry if available. |
| Blood Glucose | Fasting: $70–100\text{ mg/dL}$<br>Post-prandial: $<140\text{ mg/dL}$ | Serum energy substrate. | • $<70\text{ mg/dL}$ (Hypoglycemia): Shakiness, sweating, confusion, syncope. Immediate Action: Stop therapy, administer $15\text{ g}$ fast-acting carbohydrate (juice, glucose tabs), notify RN.<br>• $>250–300\text{ mg/dL}$ (Hyperglycemia / DKA): Risk of diabetic ketoacidosis; check for ketones; hold vigorous exercise. |
| Cardiac Troponin (I / T) | Troponin I: $<0.04\text{ ng/mL}$ | Biomarker released during myocardial infarction (cardiac muscle necrosis). | • Elevated / Trending Up: Indicates active myocardial infarction or acute cardiac injury. HOLD THERAPY until cleared by physician/cardiology. |
4. Interprofessional Healthcare Team Roles & SBAR Communication
Occupational therapy operates within a multidisciplinary ecosystem. Seamless coordination between disciplines prevents duplicate services, minimizes errors, and optimizes client recovery.
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| THE INTERPROFESSIONAL REHABILITATION TEAM |
| |
| [OTR / COTA] [PHYSICAL THERAPY] [SPEECH-LANGUAGE (SLP)] |
| • ADLs / IADLs • Gross motor mobility • Cognitive-communication|
| • Upper extremity function • Gait & ambulation • Swallowing / Dysphagia|
| • Adaptive equipment • Lower extremity biomech• Aphasia rehabilitation|
| • Environmental mods • Balance & transfers • Motor speech disorders|
| |
| [NURSING (RN / LPN)] [PHYSICIAN (MD / DO)] [SOCIAL WORK / CASE MGMT]|
| • Medical management • Diagnostic oversight • Discharge disposition |
| • Medication admin • Surgical interventions • Insurance / DME auth |
| • Wound care & vitals • Medical clearance • Community resources |
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The SBAR Communication Protocol
The SBAR (Situation, Background, Assessment, Recommendation) framework is the healthcare gold standard for rapid, accurate, and actionable interprofessional communication.
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| THE SBAR COMMUNICATION MODEL |
| |
| [S - SITUATION] ---> State who you are, the client's name/room, |
| and the immediate clinical problem. |
| *Example:* "Hi, this is Alex, COTA in Room 412. Mr. Davis became dizzy |
| and diaphoretic during seated grooming." |
| |
| [B - BACKGROUND] ---> Provide relevant clinical context, diagnosis, |
| onset date, and baseline status. |
| *Example:* "He is Post-Op Day 2 right total hip replacement with a |
| baseline BP of 120/75." |
| |
| [A - ASSESSMENT] ---> Share your objective findings and vital signs. |
| *Example:* "His current BP dropped to 86/54, HR is 98, and SpO2 is 96%. |
| He is pale and exhibiting signs of orthostatic hypotension." |
| |
| [R - RECOMMENDATION] ---> Clearly state what action or order you require. |
| *Example:* "I have reclined him in bed with legs elevated. Can you come |
| evaluate him and verify if we should administer IV fluids?" |
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5. Clinical Precautions & Movement Contraindications
Adherence to surgical and medical precautions is a core safety standard evaluated on the NBCOT examination. The COTA must weave these precautions seamlessly into all ADL and mobility training.
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| COMMON CLINICAL PRECAUTIONS MATRIX |
| |
| [WEIGHT-BEARING] [STERNAL PRECAUTIONS] [SPINAL PRECAUTIONS] |
| • NWB: 0% weight • No push/pull with arms• No Bending (spine) |
| • TTWB: <10-15% (egg shell)• No lifting >5-10 lbs • No Lifting >5-10 lbs |
| • PWB: 20-50% weight • No bilateral shoulder • No Twisting trunk |
| • WBAT: As tolerated flex/abduct >90 deg • Log-roll for all bed |
| • FWB: 100% full weight • Hug pillow to cough mobility |
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Detailed Clinical Precautions Reference
| Precaution Category | Clinical Context / Surgeries | Mandatory Movement Restrictions | COTA Intervention & Safety Strategy |
|---|---|---|---|
| Sternal Precautions | Post-Coronary Artery Bypass Graft (CABG), valve replacement, or open heart surgery via median sternotomy. | • NO pushing or pulling with upper extremities (e.g., pushing off chair armrests during sit-to-stand).<br>• NO lifting $>5–10\text{ lbs}$.<br>• NO bilateral shoulder abduction or flexion $>90^\circ$.<br>• NO reaching behind back (fastening bra, reaching into rear pocket). | • Teach client to cross arms and hug a sternal pillow to the chest when coughing or sneezing.<br>• Train sit-to-stand transfers using lower extremity momentum and leg strength without pushing through armrests.<br>• Use front-closure garments to avoid reaching behind the back. |
| Spinal Precautions (BLT) | Post-laminectomy, spinal fusion, discectomy, or vertebral compression fracture. | • No Bending: Maintain a neutral spine; do not bend forward at the waist.<br>• No Lifting: Do not lift, carry, or push items $>5–10\text{ lbs}$.<br>• No Twisting: Keep shoulders and pelvis aligned in the same plane. | • Teach the log-roll technique for all bed mobility (rolling shoulders, hips, and knees simultaneously as a single unit).<br>• Provide adaptive equipment (reacher, sock aid, long-handled sponge) for lower body dressing and bathing to avoid lumbar flexion. |
| Weight-Bearing Restrictions | Lower extremity fractures, joint replacements, tendon repairs, or osteotomies. | • NWB (Non-Weight Bearing): $0%$ weight; foot cannot touch the floor.<br>• TTWB / TDWB (Toe-Touch / Touchdown): Foot may touch floor for balance only ($<10–15%$ body weight; "crushing an egg").<br>• PWB (Partial Weight Bearing): Typically $20–50%$ of body weight.<br>• WBAT (Weight Bearing As Tolerated): Client dictates weight based on pain.<br>• FWB (Full Weight Bearing): $100%$ weight permitted. | • Train non-weight bearing lower extremity positioning during commode transfers, seated lower body dressing, and grooming.<br>• Ensure client does not step down on a restricted lower extremity when standing to pull up trousers. |
| Deep Vein Thrombosis (DVT) & PE Signs | Post-surgical immobility, trauma, hypercoagulability, total joint arthroplasty. | • DVT Red Flags: Unilateral lower extremity swelling, localized calf warmth, erythema, tenderness on palpation.<br>• Pulmonary Embolism (PE): Sudden onset dyspnea, sharp pleuritic chest pain, rapid tachycardia, cyanosis, coughing up blood. | • If DVT symptoms are observed: HOLD THERAPY IMMEDIATELY, do not massage or ambulate the limb, place client on bed rest, and notify the RN/physician for immediate Doppler ultrasound orders.<br>• If PE symptoms appear: Activate emergency medical response (Code Blue). |
| S/P Craniotomy / Craniectomy Precautions | Post-craniotomy or bone flap removal (craniectomy) following severe TBI, aneurysm, or stroke. | • For craniectomy: Strict helmet protocol when out of bed to protect exposed brain tissue; DO NOT lie client on the bone flap defect site.<br>• Avoid head-down/trendelenburg positions and aggressive Valsalva maneuvers that increase Intracranial Pressure (ICP). | • Fit protective helmet prior to any mobilization or ADL transfer.<br>• Keep head of bed elevated $\ge 30^\circ$ unless specifically counter-ordered. |
6. Clinical Scenario: COTA Chart Review & SBAR Action
Clinical Case Vignette: A COTA is reviewing the electronic health record of a 74-year-old female in the acute cardiac step-down unit who is Post-Op Day 2 following a triple Coronary Artery Bypass Graft (CABG). The order requests: "OT evaluation and treat for ADL independence and home safety."
Chart Review Findings:
- Orders: Sternal precautions strictly active; WBAT bilateral lower extremities; telemetry monitoring.
- Vitals (0700): BP $118/74\text{ mmHg}$, HR $82\text{ bpm}$ (regular sinus rhythm), RR $16$, $SpO_2$ $96%$ on $2\text{ L}$ nasal cannula.
- Morning Lab Panel: Hemoglobin $7.4\text{ g/dL}$ (down from $9.2\text{ g/dL}$ yesterday), Hematocrit $22%$, Platelets $180,000/\mu\text{L}$, Potassium $4.1\text{ mEq/L}$.
COTA Clinical Decision-Making & Interprofessional Action:
- Recognizing the Safety Hazard: The COTA notes that the client's Hemoglobin has dropped to $7.4\text{ g/dL}$ ($<8.0\text{ g/dL}$ threshold), indicating significant post-surgical anemia and a high risk of cardiac ischemia or syncope.
- SBAR Communication with RN:
- Situation: The COTA contacts the primary RN to discuss the client's hemoglobin drop before initiating out-of-bed ADL training.
- Background: Client is POD 2 post-CABG with sternal precautions.
- Assessment: Hemoglobin dropped to $7.4\text{ g/dL}$; standing grooming tasks present an elevated fall and syncope risk.
- Recommendation: The COTA checks if the physician ordered a blood transfusion (PRBCs) and coordinates to postpone standing ADL training until after transfusion, or adapt the current session to gentle, seated edge-of-bed upper body hygiene.
- Treatment Session Execution: With nursing clearance, the COTA conducts a seated edge-of-bed session focusing on sternal-safe grooming techniques (hug-pillow strategy, avoidance of pushing through bed rails) while continuously monitoring telemetry and pulse oximetry.
Test Your Knowledge
A COTA is reviewing morning laboratory results for an inpatient who had a total knee replacement two days ago. The client's platelet count is reported as 14,000/uL. How should the COTA adapt the scheduled occupational therapy intervention?
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Test Your Knowledge
During a seated morning grooming session, a client who underwent spinal fusion surgery 3 days ago complains of sudden lightheadedness. The COTA measures the client's blood pressure, which has dropped from 124/78 mmHg (supine) to 92/56 mmHg (sitting), accompanied by visible pallor and diaphoresis. What is the COTA's immediate priority action?
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Test Your Knowledge
A COTA is working on sit-to-stand transfers with a client who recently underwent open-heart surgery via a median sternotomy. Which movement instruction is essential for strict adherence to sternal precautions?
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Test Your Knowledge
A COTA notices that a client's right calf is visibly swollen, warm to the touch, and significantly erythematous compared to the left leg, and the client reports sharp calf tenderness. Which action should the COTA take first?
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