DOCUMENTATION IN OT
TYPES OF RECORDS
 Clinical Records
- Patient care (ex.: OT notes, referral
notes, assessment notes)
 Administrative or Departmental Records
- Statistical records, personal
management records, equipment supply
records, financial records
PURPOSE
 Provide legal, serial record of client’s
condition (legal document)
 Information resource for client care to
facilitate effective interventions
 Communicate information about client
from OT perspective (can be used when a
patient or client transfers to another OT)
 Provide data for use in intervention ,
evaluation, research and education (this will
be used as a proof for reimbursement to
their insurance
PURPOSES OF RECORD KEEPING
 For betterment of patient care
 Education
 Communication (OTs to parents, OTs to
OTs)
 Third party payers, reimbursement
 Social benefits (Ex. SSS)
 Legal aspects
 Research
 Motivation tool
 Administrative control
AUDIENCE
1. Medical Professionals
2. Education professionals
3. Accreditation agencies
4. Payers (Insurance companies)
5. The client/caregivers
CONTENTS
1) Function and purpose
- records should be clear and
purposeful
- for OT notes, it’s to record
the activities per session
2) Communicability
- Records should be clear and
communicable because this
will be shared to doctors,
teachers, etc.
3) Standardization
- Achieve consistency which
is essential for comparison
- Ex.: evaluation and re-
evaluation uses the same
format to see the difference/
improvements/ problems
solved
4) Form development and design
- Ex.: color, sizes, font style of
the paper must be consistent
5) Ownership and Retention
- All records are owned by
clinic and cannot be released
without permission
Documentation in Clinical Settings
In hospitals we have rehabilitation facilities, out-
patient clinics, mental health centers, and home
health. Similar types of documentation are used
although the frequency of documentation may vary.
In clinical documentation, it generally involves
reporting and interpreting a client's response/s or
assessments in interventions in a medical record.
These are the things that must be seen in a
document in an OT practice.
● Date of completion of report
● Full signature and credentials (of the OT)
● Type of document (if its OT notes, initial
evaluation)
● Client name and case number on each
page (not just in the first page)
● Acceptable abbreviations as determined by
the facility
● Acceptable terminology as determined by
the facility (always follow the uniform
terminology and abbreviations in OTs)
 ● Corrections made with a single line
through the error and initials of person
who made the error are written above
● No use of an eraser or correction tape or
fluid
● Record storage and disposal that complies
with federal and state laws and facility
procedures
● Protections of confidentiality (we are not
allowed to put other client’s name sa
patient’s document, bali dapat name rajd sa
tagiya anang document ang naa)
● Black or blue ink, never pencil (Sames,
2005) - this applies to hand written notes
Documentation of the Initiation of Occupational
Therapy
● Screening - if the client is seen for
screening or introduction prior to an
evaluation, a short note is usually written in
the medical records summarizing the
conversation and the results of the
screening. (In abroad, it's the OT assistant
who is usually taking down the notes but
here in the PH, it's the direct OTs are the
one doing it)
● Evaluation - this is written by the OTs to
document the starting point of the
Occupational therapy intervention and it
contains factual data collected during the
evaluation process and the interpretation of
the evaluation findings.
There is a need to document the OT services
before interventions can be implemented.
The very first evaluation is initial evaluation nya
mao to di nalng ko mo discuss unsay sulod ani
pero ang initial evaluation will take place first
before the treatments begin and is the
foundation of selecting treatment objectives
and methods. It also identifies the performance
areas and components.
Typically, the evaluation report contains the
following:
● Identifying information and background
information
● Referral information
● Evaluation procedures and/or test used
● Occupational profile (the client’s perception
of the need for occupational therapy. The
context that supports or hinder occupational
performance or brief history of Occupation)
● Findings or results of the evaluation process
● An interpretation of the meaning of the
findings or results that reflects the
occupational needs of the client
● A plan, including goals, frequency, duration,
and location of intervention
● Signature and credentials of the
occupational therapist (printed name of the
OT and licensed number)
Documentation of Continuing OT Services
 Progress notes - these are used
periodically to document the
interventions, progress towards functional
goals, into updating of the goals and
interventions/ treatment plan.
 Clinical notes/OT notes - these are used
to document individual occupational
therapy sessions. It’s usually written after
each intervention session
One of the most common forms of documenting the
client’s progress is through the “S-O-A-P” notes.
S - Subjective (experience of the client)
O - Objective (OT’s objective, observation and
measurements)
A – Assessment (Clinician’s interpretation of the
meaning of O-Section)
P – plan (Plan description of what will happen next)
Soap notes is a practice the strengthens the
communication of the OT professionals
● RUMBA (Relevant, Understandable,
Measurable, Behavioral, Achievable)
● POMR (Problem-Oriented Medical Record)
- SOAP
- BIRP (Behavior, Intervention, Response,
Plan)
 Documentation of Discontinuation of
Occupational Therapy
Two types of documentation in discontinuation:
● ENDORSEMENT NOTES
- Used to document client’s basic
information, the problems and
improvements for the continuation of
treatment.
- made for the next OT if ever the
client transfers.
- Content:
(1) name, age, sex, address, (5) the
referral source and the services
requested, (6) the problems list, (7)
the management and activities that
were given during the past OT
sessions, (8) list of improvements
and progress after a number of
treatment sessions, (9) the
recommendation from the past OT to
the next therapist.
● DISCHARGE NOTES
- These documents are used as a
summary of the course of therapy
and any recommendations.
- Content: therapy process, goal
attainment, the functional outcome
of the client’s interventions
(summary of the client’s functional
status at the initiation of the
occupational therapy services, from
the very first intervention to the
last), recommendations for follow-
up, home instructions program, and
the signature, credentials and the
date of the OT.
OTPF (GOALS)
 SMART (Specific, Measurable, Attainable,
Realistic, Time-bounded)
Specific: tangible outcome, what does client want
to do
Measurable: essential in reimbursement as this will
track the progress and gives concrete data on the
client’s performance
Attainable: how much time you have with the client
along with their current level of functioning
Realistic: be realistic in approaching the goals of
the client, do something the client can actually
achieve
Time-Bound: certain time for the goal
 ABCD (Audience, Behavior, Condition,
Degree)
- Audience: performer
- Behavior: desired functional
behavior to be demonstrated or
increased as outcome of
intervention
- Condition: circumstances under
behavior must be performed
- Degree: time period goal to be met
- Ex: The child (audience) will be able
to eat (behavior) using a spoon
without difficulty (condition) within 8
weeks of the OT session (duration).
 CARE (Clarity, Accuracy, Relevance,
Exceptions)
- Not usually used in the Philippines
and other places but there are still
OTs that will use this format.
GUIDELINES
➔ Legible handwriting (prefer handwritten than
encoded).
➔ Correct grammar and spelling
➔ Be concise, but complete, non-important
details should be left out.
➔ Be objective with clear distinctions between
facts vs behaviors and opinions vs
interpretations (the therapist should not be
biased, be more objective and more aware
of our opinions vs interpretations/
observations).
➔ Be current and accurate, active rather than
passive voice.
➔ Use first person language at all times (ex:
child with autism or child with a mental
disorder).