Chances are you didn’t become an occupational therapist because you wanted to do documentation. But writing good documentation is essential for providing quality care to patients and is generally required to receive payment for the services you provide. In this post, we share some tips that will help you write better documentation and offer a template to help speed up your process.
A New Perspective on Documentation
Though occupational therapy documentation is a practical necessity, providing good documentation on every patient also helps to demonstrate your value as a quality provider. It proves the value of what you’re doing. It gives you the ability to communicate with other healthcare providers, to defend treatment choices, and to track progress.
7 Characteristics of Effective Occupational Therapy Documentation
Although you’ll customize your occupational therapy documentation to each patient situation and treatment, there are seven characteristics of effective documentation that apply in every case.
- Highlights the value of the service — Every note you write should educate others on the value of occupational therapy. It’s something to think about each time you sit down to type up your documentation.
- Records each item of care or intervention — Documentation provides the evidence for care provided and serves as a foundation for future care. Keep in mind the saying, “if you don’t write it down, it didn’t happen.”
- Describes observations and reasoning behind choices for treatment — Notes should also include clinical reasoning and observations of a patient’s response to each intervention. They should reflect the what, why, and how of each visit and explain how the interventions will assist the patient with meeting a functional goal. (More on this later.)
- Includes non-treatment interactions, including phone calls — Documentation should also include non-treatment interactions. This includes phone calls with the patient or other providers regarding the patient’s care, reports sent on the patient’s behalf, and cancellations, offering a more complete picture of all of the interactions that go into the care you provide.
- Articulates improvements — Share your observations of improvements in specific functional areas. This could include things like changes in the progression of skills, such as a patient being able to sit at the side of a hospital bed to eat meals, or changes in the use of assistive devices, like no longer requiring sock aids.
- Concise — Documentation should include only relevant information with the most important details of sessions, the treatment plan, and expected outcomes. You don’t want to be generic, but neither do you want to include unnecessary information. Also make sure the content will be clear to someone without your expertise. Be careful of abbreviations that could be misunderstood.
- Legible — If you’re hand-writing notes, make them easy to read. Illegible documentation can lead to patient-safety issues and can delay care. Better yet, use an EMR so legibility is never an issue.
Template for Documentation
Certain key pieces of information should always be included in patient documentation, such as patient information, insurance information, diagnosis codes, and what are often referred to as SOAP notes.
Though you may collect additional information, the following list contains the essentials you’ll want to include for every patient and every session:
- Date of birth
- Evaluation date
- Diagnosis and treatment diagnosis codes ( CPT — Common Procedural Technology codes)
- Referring physician
- Recommended visit frequency
- SOAP notes
SOAP Notes Recommendations
SOAP notes represent the clinical portion of patient notes, serving as an important part of the documentation.
SOAP is an acronym for subjective, objective, assessment, plan. It’s a widely-used method of documentation for healthcare providers across specialties. It’s also an effective way to structure and organize documentation for consistency and comprehensiveness.
Subjective — Set the stage for the story about your patient. It’s a good idea to open with patient feedback, using statements like, “Patient states that. . .” or “Patient had a setback because. . .” Keep it concise and descriptive.
Objective — The objective portion of the documentation goes into detail about observations and interventions. It’s generally the longest portion and should contain test results and objective measurements.
Assessment — This is where you’ll justify your involvement in the patient’s care and show expertise and clinical reasoning. Demonstrate the value of the care the patient is receiving. Link the patient’s story with the objective measurements, tests, and observations during the treatment session to describe how the information fits together and the recommended future treatment.
Plan — Show appropriate strategic planning for care. It might include continuing care, what you plan to add in the near future, and any goals.
Documentation is an important part of providing quality care and receiving payment for treatment. Using a template and knowing how to document the right level of information can make it a faster and easier process — so you can spend more time helping patients.