The healing process doesn’t end the moment you check out of the hospital. For many, an occupational therapist (OT) plays a valuable role in helping them fully recover.

Without an OT specialist’s assessments, evaluations, and treatment plans, a vast number of patients would have difficulty returning to their old lives and finding pleasure in their regular activities. Succinct and clear occupational therapy documentation is therefore key.

To achieve their goals, OT specialists need to balance a variety of tools, which can often become hectic and ineffective. In this article, we aim to help therapists understand the importance of occupational therapy documentation so that you can understand how to take better occupational therapy notes and help you craft more accurate goal-oriented online treatment plans.

Occupational Therapy: What Is It?

Occupational therapy is a health profession that focuses on promoting health and wellness through the use of occupations. Occupations, more specifically, refers to the day-to-day activities that people engage in, and which bring purpose and meaning to their lives.

These activities might be things that people want to do, need to do, or are expected to do, per the World Health Organization.[1]

Simply put, occupational therapy helps people return to the lives they had before their injury or illness. It may be something as trivial as preparing a cup of coffee for a loved one or being able to take part in social activities.

These mundane activities are defined as “activities of daily living” or ADLs by OT professionals, and play a crucial role in the healing process, helping patients to speed up their recovery.

The Stages of Occupational Therapy

As mentioned above, the primary goal of occupational therapists is to help patients take part in the activities of everyday life. As simple as it may sound, it can be quite a lengthy process that entails various plans, strategies, and good engagement for achieving this outcome.[2]

This is why occupational therapists follow clear guidelines to ensure that patients reach their goals on time, and effectively. Here, we consider the guidelines on Initial Assessment, Planning, Intervention, and Cooperation.

Guideline

Description

Initial Assessment

  • The occupational therapy process begins with an initial assessment where therapist and client determine the problem and goals they want to achieve.
  • Here, they often use tools such as interviews and observations to better understand what a client is dealing with and the best approach to pursue.

Planning

  • Based on the results of the assessment, OT therapists will create an occupational therapy treatment plan that’s aligned with the needs, style, and preferences of their patient.
  • They may consider other factors to decide on the most appropriate interventions, such as whether OT will be part of a larger mental health treatment plan.

Intervention

  • This stage of the occupational therapy process focuses on teaching the client how to adapt to their new life and the techniques they could use to perform everyday tasks.
  • Some tools used in this part of the process may include resources and equipment that encourages independence, for example.

Cooperation

  • Healing from an injury or illness is a process that not only takes time but also requires the help of various professionals.
  • Occupational therapists understand this fact and have a holistic approach that involves working with other specialists, such as speech therapists or physical therapists.

Occupational Therapy Documentation: a Few Guidelines

OT professionals are aware of the vital role documentation plays. Occupational therapy forms and notes are not only documents that patients use to file insurance claims, but they are also essential tools in helping track patient progress.

However, efficient, accurate occupational therapy documentation can be a challenge.

First of all, healthcare institutions may not have the latest tech tools to simplify work; on top of a heavy workload, admin can become tedious.[3] In the scheme of things, this can add up to a huge amout of time spent documenting – not usually reimbursed – which is better spent interacting with clients.

So, how can occupational therapists ensure that the time they spend documenting is fruitful?

Occupational therapy forms and notes are not only used to help patients file insurance claims, but they are also essential tools in helping track patient progress.

Here are a few general guidelines they should consider and follow:

If You Didn’t Write It Down, It Didn’t Happen

As mentioned above, occupational therapy notes facilitate client reimbursements by their insurance companies, while helping practitioners track their progress.

Moreover, documenting what happens during the sessions, for example using OT therapy notes software, can be proof of the effectiveness of the tools and methods used and establish if the occupational therapy treatment plan is suitable for the needs of your patient.

Forgetting or neglecting to write down important details about the session may make it more difficult to assess the efficiency of your approach and make any necessary adjustments.

Don’t Go Overboard with Details

That said, taking good occupational therapy notes doesn’t mean that writing down every detail of your encounter.

Try to determine if the details add to the story and help you better assess your patient’s mental and physical state before writing anything down. That they sat on the chair may not be relevant, but their position and posture might be telling and help to improve the client’s function.

Where you find them appropriate, established note-taking standards such as SOAP and BIRP frameworks can help you structure your session notes.

Specific Observations

Be specific when documenting your observations, the interactions between the patient and yourself, and the methods employed.

Include objective measurements, such as:

  1. Level of independence (MIN A, CGA, etc.)
  2. Range of motion measurements (AAROM, AROM, etc.)
  3. Manual muscle tests
  4. Functional reporting measures (DASH screen, etc.)
  5. Wound healing details

Arguments and Hard Evidence

Establish the value of your occupational therapy treatment plan by providing medical reasoning and expertise. Show how the objective measures are an accurate reflection of the case and how everything ties together.

Note the trajectory that you think the patient should follow and the OT methods and tools and might help them get there.

Don’t Overdo Jargon

While professional language is encouraged in occupational therapy forms and notes, try to limit the use of jargon, slang or abbreviations. Only use abbreviations that are regulated and approved by your institution.

Specifically,

  • Poor spelling
  • Confusing slang, or
  • Unapproved abbreviation terms can jeopardize the effectiveness of the document.

If an insurance company or other OTs don’t understand an OT document, for example, they might disregard it – many similar admin errors can compromise the effectiveness of an OT treatment plan.[4]

Be Specific About Patient Improvement

If you want to highlight the value and effectiveness of your occupational therapy treatment plan, write down the specific functional areas that your approach helped improve.

Note when a patient reaches a goal, such as the ability to stand unaided.

Note Non-Treatment Interactions Too

Healing from an injury or illness requires a holistic approach that incorporates both the body and the mind.[5]

Occupational therapists should understand that this process doesn’t end the moment a patient steps out of their door.

This is why it’s vital for them to write down any information and interactions that take place outside the treatment too, such as patient phone calls, reports from other medical professionals, or data from fitness apps that may be part of treatment.

Fill in Documentation in a Timely Manner

The longer you wait to document a session with a patient, the higher the risks that you will forget important details of your session. Ideally, you should write down information during the session or as soon as the appointment ends.

However, most OTs have a packed schedule and see patients back to back, which means little time for filling out documentation.

Where this is the case, make sure to complete any forms in a timely manner, such as at the end of the day, to ensure that the information is still fresh. Make it easy for clients to fill out their own therapy intake or informed consent documents before arriving, to further streamline your practice management.

With plenty of occupational therapy documentation examples online and included in treatment software, there are now many great guidelines to follow when creating yours.

6 Best Occupational Therapy Apps

Lack of time, heavy workloads, and immense pressure aren’t the only challenges that occupational therapists face. They work with patients that suffer from a wide variety of ailments, which can make interaction difficult, to say the least.

From the huge array of therapy software out there, we’ve compiled a list of the best occupational therapy documentation software that can make sessions go smoothly and help you provide the best care to your patients.

Software

Details

Verbally OTVerbally is an excellent OT software that brings speech to those who are unable to express themselves.

All that your patients have to do is tap in what they want to say and the app will say it for them.

NameVerbally
PriceFree
Good ForCommunication, Health Engagement
Websitehttps://apps.apple.com/us/app/verbally/id418671377

Software

Details

Tap To Talk OTThe name says it all: this app will help your patients get a voice by taping in what they want to say.

And, the beauty of it is that it’s available for free on almost every operating system.

NameTap To Talk
Price$99.95 yearly
Good ForCommunication, Client Engagement
Websitehttps://play.google.com/store/apps/details?id=com.CyberCityGames.TapToTalk&hl=en

Software

Details

GoCanvas OTInstead of writing down notes on a piece of paper and trying later to decipher your scribbling, why not log and track down everything from your phone or tablet?

This HIPAA-compliant app simplifies the documentation process by allowing you to create personalized plans, enter progress notes, monitor the patient’s progress, and so on.

NameGoCanvas
PriceFree+
Good ForNote-Taking, Communication, Monitoring Progress
Websitehttps://www.gocanvas.com/

Software

Details

Simple Practice OTMost of the apps that you will find online focus on streamlining sessions and helping you track and monitor the effectiveness of your treatment plan.

But, that’s only part of being an OT professional. You also need to take care of finding new clients, sending invoices, and growing your business. That’s where SimplePractice can make a difference.

This app will help you manage appointments, documentation, as well as communication. It also takes care of customer billing as it allows you to send invoices and get paid.

NameSimplePractice
Price$39+ monthly
Good ForPractice Management, Communication, Scheduling, Telehealth
Websitehttps://simplepractice.com/

Software

Details

DrChrono OTDrChrono is another excellent OT billing system.

User-friendly, fully customizable, and HIPAA-compliant, this app is everything you need to manage billing, patient intake and scheduling, create custom OT and other relevant assessment forms, and so on.

It really is an OT software that will make your life easier and take the hassle out of the documentation and billing processes.

NameDrChrono
Price$199+ monthly
Good ForScheduling, Billing, Note-Taking, Practice Management, Communication, Psychology Tools
Websitehttps://www.drchrono.com/

Software

Details

TheraOffice OTWith a drag and drop interface, TheraOffice is an e-clinic software system designed to help OTs manage everything from documentation and patient engagement to accounting and scheduling.

It’s an all-encompassing care management solution ideal for medium to large institutions, but that doesn’t mean that individuals therapists or small clinics can benefit from its features too.

NameTheraOffice
Price$50+ monthly
Good ForScheduling, Billing, Practice Management, Communication, Note-Taking
Websitehttps://www.theraoffice.com/

Final Thoughts

Occupational therapy is a vital component of the healing process. Patients who are recovering from a debilitating illness or injury need help in re-engaging in regular activities and getting back to their old lives.

The stakes are high and occupational therapists are under a lot of pressure to provide the best solutions and care for their clients. This task can become a bit easier to accomplish with the right set of guidelines and a well-designed piece of e-health software.

Fortunately, you can find a wide variety of OT apps out there, as well as numerous occupational therapy documentation examples. What’s left is that you choose the ones that best fit your needs and goals.

References

  1. ^ WFOT. (2013). Definitions of Occupational Therapy from Member Organisations. Retrieved from https://www.wfot.org/resources/definitions-of-occupational-therapy-from-member-organisations
  2. ^ Rebeiro, K. L. (2000). Client perspectives on occupational therapy practice: Are we truly client-centred?. Canadian Journal of Occupational Therapy, 67(1), 7.
  3. ^ Gawande, A. (2018). Why doctors hate their computers. The New Yorker, 12.
  4. ^ Scheirton, L., Mu, K., & Lohman, H. (2003). Occupational therapists’ responses to practice errors in physical rehabilitation settings. American Journal of Occupational Therapy, 57, 307.
  5. ^ Stern, P. (2005). A holistic approach to teaching evidence-based practice. American Journal of Occupational Therapy, 59(2), 157.

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