DOCUMENTATION IN OT Caitlin Tagarda

OT 101 | OT-1B Padayon!

→ Communicability (capable of being understood &

transmitted)
TYPES OF RECORDS
→ Standardization (achieve consistency, essential
for comparison)
★ CLINICAL RECORDS → Form development & design (size, font, style)
→ OT notes, referral notes, assessment notes, → Ownership & retention (owned by clinic and can’t
progress notes, IE notes be released w/out permission)
★ ADMINISTRATIVE/DEPARTMENTAL RECORDS
→ Statistical records, personal management ESSENTIAL FEATURES OF CLINICAL DOCUMENTATION
records, equipment & supply records, financial
records
→ Date of completion of report
★ PURPOSE IN MAKING RECORDS: → Full signature & credentials
→ Provide a legal, serial record of client’s condition → Type of document
→ Information resource for client care (to facilitate → Client name & case number on each page
effective intervention) → Acceptable abbreviations as determined by the
→ Communicate information about client from OT facility
perspective (if mo transfer ug lain OT or center) → Acceptable terminology as determined by the
→ Can be used by a covering therapist in the facility
absence of primary therapist → Corrections made with a single line through the
→ Enhances communication among healthcare or error and initials of person who made the error
educational team members are written above
→ Provide data for use in intervention, program → No use of an eraser or correction tape or fluid
evaluation, research, education, and → Record storage and disposal that complies with
reimbursement federal and state laws and facility procedures
→ Protection of confidentiality
★ PURPOSES OF RECORD KEEPING: → Black or blue ink, never pencil
→ For betterment of patient care
→ Education DOCUMENTATION OF THE INITIATION OF OT
→ Communication
→ Third party payers, reimbursement
→ SCREENING
→ Social benefits
→ EVALUATION (IE, Initial Evaluation)
→ Legal Aspects
▪ A report written to document the starting point of
→ Research
the OT intervention
→ Motivation Tool ▪ Contains factual data collected during the
→ Administrative Control evaluation process
▪ Contains interpretation of initial findings
★ AUDIENCE: ▪ The need for OT services must be documented
→ Medical Professionals (Doctors, nurses, before interventions can be implemented
psychologist, case worker, etc.) → Evaluation report contains the ff:
→ Education Professionals ▪ Identifying information & background information
→ Accreditation Agencies (DOE, HMOs, Medicare) (name, age, diagnosis, date of referral, date of
→ Payers report, precautions, contraindications)
→ The client or caregiver ▪ Referral information (date and who referred the
client and why)
★ CONTENTS: ▪ Evaluation procedures and/or tests used
→ Function & purpose ▪ Occupational Profile (client’s perception of the
need for OT, context that support or hinder

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DOCUMENTATION IN OT
OT 101 | OT-1B
occupational performance, brief occupational
history)
▪ 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
INTERVENTION PLAN DOCUMENTATION
→ A prioritized problem list
→ Goals related to the problem list indicating potential
function and improvement
→ Structure of the goal statement
★ LONG TERM GOALS (LTGs)
INTERVENTION IMPLEMENTATION DOCUMENTATION
→ Goals related to problem list indicating potential
function and improvement
→ Change in activity limitations and participation
restriction will occur prior to the termination of
intervention in order to achieve the desired
functional outcome
→ Duration of intervention is atleast 4-6 months
★ SHORT TERM GOALS (STGs)
→ Component sub skills which are to be achieved
over shorter time frames, leading to the
attainment of the LTG
→ Duration is 2 weeks – 4 months of OT sessions
★ STRUCTURE OF THE GOAL STATEMENT
→ (A) – The person/audience who will exhibit the
skill
→ (B) – The desired functional behavior that is to be
demonstrated or increased as the outcome of
intervention
→ (C) – The circumstances under which the behavior
must be performed or the conditions necessary
for the behavior
★ PROGRESS NOTES
→ (D) – The degree to which the behavior is
→ Used periodically to document care coordination, also
demonstrated
★ LTGs & STGs SHOULD BE WRITTEN IN
→ SMART – Specific, Measurable, Attainable,
Realistic, Time-bound
Caitlin Tagarda
Padayon!
▪ Specific – refers to tangible outcome
(what does the client want to do)
▪ Measurable – essential for
reimbursement and tracking progress,
gives concrete data on the degree of the
client’s performance
▪ Attainable – how much time you have
with the client along with the current level
of functioning
▪ Realistic – important to ensure that your
client wants to reach their goals,
motivation can have an enormous impact
on progress, process of coming up w/
realistic or relevant goals begins when you
take your clients occupational profile
▪ Time-bound – designated date and time,
varies depending on the setting
→ CARE – Clarity, Accuracy, Relevance, Exceptions
→ Activities, procedures, and modalities used
→ Client’s response to treatment and the progress
toward goal attainment as related to the problem
list
→ Goal modification when indicated by the
response to treatment and rationale for changes
in goals needed
→ Attendance and participation with treatment
plan
→ Statement of reason for individual missing
treatment
→ Assistive/adaptive equipment, orthoses and
prosthesis if issued or fabricated, and specific
instructions for the application and/or use of the
item including wearing schedule and care
→ Home program compliance
DOCUMENTATION OF CONTINUING OT SERVICES
including intervention, progress towards functional goals,
update goals, intervention, or treatment plan, usually
written after each intervention session, describes client’s
reaction to intervention
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DOCUMENTATION IN OT Caitlin Tagarda
OT 101 | OT-1B Padayon!

★ CLINICAL NOTES/OT NOTES

→ Used to document individual occupational therapy
sessions, can be done briefly, everyday or every session

★ SOAP
→ Subjective – information reported by the client, family, or
significant other
→ Objective – Diagnosis, medical information and history,
measurable and observable data obtained through
assessments
→ Assessment – Therapist interpretation and clinical
reasoning based on objective data. Includes analysis of
client’s status and goals and a prioritized problem list
→ Plan – The therapist’s specific plan of intervention to
resolve identifies problems and meet stated goals

★ RUMBA
→ Relevant, Understandable, Measurable, Behavioral,
Achievable
★ POMR
→ Problem-Oriented Medical Record
▪ SOAP – Subjective, Objective, Assessment, Plan
▪ BIRP – Behavior, Intervention, Response, Plan

★ DOCUMENTATION TIPS
→ Legible handwriting
→ Correct grammar and spelling
→ Be concise but complete
→ Be objective with clear distinctions between facts
and behavioral data and opinions
→ Use educational terms rather than medical
jargons
→ Be current and accurate, active rather than
passive voice
→ Avoid slang or emotionally charged words
→ Use first person language at all times
→ Follow instruction and/or program guidelines