Environment – can either a support or barrier of the occupation of the client

 Important to consider the environment of an individual when giving interventions

Physical Environment – natural and built surroundings in which daily life occupations occur

Social Context – presence of, relationships with, and expectations of persons, groups, and
populations with whom clients have contact

Cultural Context – customs, beliefs, activity patterns, behavioral standards, and expectations
accepted by the society of which a client is a member

Personal Context – features of the individuals that are not part of a health condition or health status

 Age, gender, socioeconomic status, educational status, group membership, population

membership

Temporal Context – experience of time as shaped by engagement in occupations

 Contribute to the patterns of daily occupations

 Engaging in leisure activities rather than in working activities if he/she is retired

Virtual Context – environment in which communication occurs by means of airwaves or computers

in the absence of physical contact

 Includes simulates, real-time or near-time environments

Teaching – Learning Process

 Important to know their ability to learn or their learning process according to their needs
 Clients have unique needs, strengths, and weaknesses
 Understand the different strategies to use in planning, implementing, carrying out, and
evaluating the performance

Reasons to Study Theories of Learning

 Provides a foundation for practice

 Guides and informs practice
 Lead to researchable questions
 Core professional responsibility

Theories of Learning – enables us to see how interesting and complex even the most seemingly
simple things can be.

 Reflect beliefs about how people think and how they store and use information

The Process of Learning

Time is encompassing all of them; begins with learner’s motivation (extrinsic or intrinsic)

1. Expectancy – established when learners are interested with the task

2. Attention – stopping of other things and concentrating on what is discussed
3. Coding – learners connect topics and experiences that are discussed and encountered.
4. Storing – stored in short-term or long- term memory
5. Retrieval – when the memories are needed
6. Transferred – generalize to all related tasks and topics
 7. Responding – generates feedback from others
8. Reinforcement – learners keep the newly learned topics; either reinforce the learning of the
learners

Behaviorist Theory

 Focuses on how observable, tangible behaviors are learned in response to some

environmental stimulation.
 Focus on observable events rather than mental processes
 The overall emphasis is on the relationship between an environmental stimulus and a
behavioral response and how learning is indicated by an observed change in behavior

Esssential Elements and Assumptions

 Behaviorists use the term conditioning to explain changes in behavior rather than learning
because behaviorist theory asserts that a person’s behavior is conditioned by events in the
environment. A behavior is gradually shaped, changed, and molded as it reflects the
environment’s response to the behavior.
 Key terms:
o Conditioning – behavior modification process that increases or decreases the
likelihood of a behavior being performed
o Stimulus – verbal, sensory, or environmental input that prompts a behavior
o Response – the reaction to the stimulus
o Fading and Shaping – strategies to develop closer and closer approximations of a
behavior
o Chaining – a stepwise process for teaching a multistep task
o Reinforcement – a stimulus that causes a behavior to be strengthened and
performed again [positive or negative reinforcement])
o Punishment – an aversive stimulus that causes a behavior to decrease in frequency
o Extinction – the process of reducing the frequency of a behavior by withholding
reinforcement

Major Assumptions:

1. Principles of learning apply equally to different behaviors and different species of animals.
(Equipotentiality)
2. Learning processes can be studied most objectively when the focus of the study is on stimuli
and responses.
3. Internal cognitive processes are largely excluded from scientific studies.
4. Learning involves behavior change.
5. Organisms are born as blank slates.
6. Learning is largely the result of environmental events.
7. The most useful theories tend to be parsimonious ones.
Behavioral Theorists

1. Ivan Pavlov - developed the theory of classical conditioning

- resulted from his initial studies of a dog’ s salivation response to a neutral stimulus
paired with an unconditioned stimulus (food), which caused an unconditioned response
(salivation).
- concluded that changes in behavior (learning) are due to experience.
 2. Edward Thorndike – connectionism, whereby learning is seen as a process of making
connections between things, understanding the relationship of a stimulus to a response
(Law of Effect)
- emphasized the role of practice and experience in strengthening or weakening
connections between a stimulus or response
- concluded that behavior is learned via the consequences of the behavior
- if a behavior were followed by a satisfying experience, it strengthens the connection, the
neutral bond between the stimulus and response, and increases the likelihood that
behavior will be produced again
3. John Watson – greatly influenced by the work of Pavlov
- introduced behaviorism; emphasized the importance of focusing on observable
behaviors

Two Laws that explained the relationship of stimulus and response:

 Law of Frequency – “the more frequently a stimulus and response occur in association
with each other, the stronger the Stimulus-Response habit will become”
 Law of Recency – “the response that has most recently occurred after a particular
stimulus is the response most likely to be associated with that stimulus”
4. B.F. Skinner – influenced by Pavlov and Watson; coined the term operant conditioning
- a response followed by some reinforcement is likely to be strengthened
- any behavior, negative or positive, can be reinforced
- used the term reinforcement rather than rewards because (1) reward implies something
pleasant or desirable, but sometimes people intentionally do things to produce
unpleasant consequences, and (2) the terms reward, pleasant, and desirable are highly
subjective terms

3 Important Factors:

 The reinforcement must follow, not precede the response

 The reinforcement should immediately follow the behavior in order to have the greatest
effect
 The reinforcement must be contingent on the response; it should not be given for an
unintended response

Difference of Classical and Operant Conditioning

- In classical, there is an unconditioned stimulus and a conditioned stimulus (who brings

the conditioned response)
- Response is automatic and involuntary
- In operant, a response is followed by a reinforcing stimulus
- Response is voluntary

Types of Interventions

1. Positive Reinforcement – presentation of a reinforcer (stimulus) immediately following a

behavior that causes the behavior to be more likely to reoccur.
a. Consumable (food)
b. Manipulative (toys)
c. Social (positive feedback to attention)
d. Activity (swinging or bouncing on lap)
 e. Possession (money or tokens)
- must be appealing to the individual for it to be effective
2. Negative Reinforcement – the removal of a stimulus immediately after a response causes
the response to be strengthened or increase in frequency
3. Punishment – aversive stimulus contingent upon a response that reduces the rate of the
response
4. Extinction – process of reducing the frequency of a behavior by withholding reinforcement
- when trying to extinguish a behavior, you may see:
o Extinction burst – occurs when the behavior gets worse before it gets better
o Spontaneous recovery – occurs when the behavior reappears after a delay, even
though not severe
- reimplementing the behavioral strategies can usually be done quite quickly and
successfully

Reinforcement Schedule – indicates which instances of behavior will be reinforced

2 main Types:

 Continuous – reinforces every instance of the behavior; usually used at the beginning of a
treatment
 Intermittent – reinforces certain demonstrations of the behavior; more effective at
maintaining the desired response
o Ratio Schedule: based on the number of behaviors required
o Interval Schedule: based on the passage of time between behaviors occurring
o Fixed Schedule: requirements are always the same
o Variable Schedule: changes randomly
 Differential – teaches individual to discriminate between desired and undesired behavior;
can be used to increase or decrease behavior
o Differential reinforcement at low rates ( DRL) and Differential reinforcement of zero
responding (DRO) – involves simple decrease or absence of behavior
o Differential reinforcement of incompatible reasoning (DRI) and Differential
reinforcement of alternate behavior (DRA) – adding an incompatible or alternate
behavior to replace original behavior

Stimulus discrimination learning – procedure which an individual can learn to emit a behavior under
certain conditions

Stimulus Generalization – when a behavior becomes more probable in the presence of one stimulus
as a result of being reinforced in the presence of another similar stimulus

Behavioral Techniques/Types of Reinforcement

 Fading – prompts or cues that guide the performance of a complex behavior are gradually
withdrawn. A prompt is a stimulus (physical, verbal, visual) introduced to control the desired
behavior
 Shaping – occurs by reinforcing successively closer approximations to the target behavior
while extinguishing preceding approximations of the behavior

Both fading and shaping involve a gradual change. Fading involves a gradual change in the stimulus
while shaping has a gradual change in the response
  Chaining – used to teach a complex behavior by reinforcing the performance of each part of
the behavior separately, in order, until the individual can complete a sequence
o Forward chaining – reinforcing the first step and then adding sequential steps
- is a natural way that you would teach yourself a task that you had to read the directions
o Backward chaining – begins with the final step of the complex behavior and then to
the second-to-the-last step, and so on, until the behavior is learned.
- it is a natural reinforcer because the task is already completed and sometimes there is
less frustration
o Total task training – occurs when individuals are asked to attempt to do all steps
from beginning to end; prompting may be provided along the way; reinforcement is
provided following the last step
- The method instills confidence when an individual is relearning a previously learned skill

4 phases of Behavioral Modification Process:

1. Screening 3. Treatment
2. Baseline 4. Follow-up

Behavioral Assessment – carried out throughout the whole behavioral modification program or
during each phase.

3 Sources of getting Information (for baseline assessment):

1. Indirect Assessment – interviews, questionnaires, role-playing, and consulting with

professionals
2. Direct Assessment – records the characteristics of behaviors that are observed
a. Topography – form of particular response
b. Amount – frequency and duration of the behavior
c. Intensity – force or magnitude
d. Stimulus control – certain behavior occurs in the presence of certain stimuli
e. Latency – time between the occurrence of a stimulus and the beginning of a
response
f. Quality of behavior
3. Functional Assessment – used to identify the cause of a problem behavior
a. Questionnaires
b. Observations: observes and describes the antecedents and immediate
consequences of the behavior in natural settings
c. Functional analysis: directly assesses the effects of controlling variables on the
problem behavior
- Environmental events are systematically manipulated to test their role as an antecedent
or consequences

Occupational Therapy and Behaviorist Theory

- Use behaviorist theory to understand human learning and guide their intervention
would analyze a complex behavior that needs to be learned
- Intervention would consist of opportunities for the person to participate in increasingly
complex behaviors, using behaviorist principles.
- Behaviorist theories emphasize observable behavior, rewarding and reinforcing
desirable behavior and reducing problematic behaviors
Social Cognitive/Social Learning Theory

- Outgrowth of behaviorist theories

- Piget and Bandura developed theories of learning that integrated social and cognitive
processes with behavioral processes
- Social Theory explains learning as occurring in a social context
- Learning can occur even in the absence of an observable change in behavior.
- Social and cognitive processes such as observing, and self-assessment promote learning

5 major Assumptions:

1. People can learn by observing others

2. Learning is an eternal process
3. People are generally motivated to achieve goals for themselves
4. Learning occurs as people regulate and adjust their own behavior
5. Feedback via reinforcement and punishment can affect learning and behavior indirectly.
- Important for a person to observe skills and behaviors via models
- Models can be live or symbolic
o Live – a person with whom the learner has actual contact
o Symbolic – pictorial or an abstract representation of behavior, such as through
tv
- A person can learn vicariously
- Attention to the behavior is very important factor
- Incentive is the anticipation that something will happen if a particular behavior is
performed or not performed
- In operant conditioning (behaviorist), reinforcement must come after the behavior has
been performed. In social cognitive, anticipated outcome might precede the behavior
being performed

Constructivist Theory

 Learners must access the information, alter or modify existing knowledge, integrate new
information with previous information, and create new understanding that is relevant to
his/herself
 Constructivism speaks more to the role of the client as an individual learner, responsible for
his/her learning
 A constructivist approach fosters intellectual potency, meaning when people seek
information, the information is more meaningful, and relevant
 Conservation of memory – people organize information they find for themselves so that it is
more efficiently and effectively retrieved for future use.
 Learners own the information, this approach fosters intrinsic approach
 Constructivism fosters people’s learning the process of discovery
 A practitioner who uses constructivist approach emphasizes skills and activities, such as
asking questions, and identifying problems
 The practitioner emphasizes client’s essential role in the process and see his/her role as
facilitating client’s progress.
 The practitioner does not provide intervention, but works to facilitate the person’s
developing his/her strategies to deal with issues
 Practitioners are alert to major issues but is neither prescriptive nor directive
5 Major Assumptions:

1. Learners must be active participants in the learning

2. Learners are capable of discovering and creating their own knowledge
3. Active participation in the learning environment enhances critical thinking and problem-
solving abilities
4. In learning, people gather information and develop problem-solving strategies
simultaneously
5. Active participations in the learning environment enhances the meaning and relevance or
learning experience and motivation for learning

Self-Efficacy Theory

 Focuses on a person’s individual beliefs about how effective he/she is or will be at learning
or completing a new skill or behavior
 Badura first articulated a theory of self-efficacy and his perspective on how behaviors are
learned and changed involved behavioral and cognitive processes
 Central thesis is that a person’s efficacy expectations, the person’s belief about how
successful or unsuccessful he/she will be at performing a skill or occupation
 Person’s beliefs and how those beliefs influence his or her performance
 Efficacy expectations determine how much effort will expend and how long they will persist
in the face of obstacles and aversive experiences
 The stronger the perceived self-efficacy, the more active the efforts

Efficacy expectations have 3 important dimensions:

1. Magnitude – the level of difficulty for a task

2. Generality – the degree to which a person’s perceived self-efficacy for one task transfers to
another
3. Strength – degree to which people believe they can be successful
 A person’s self-efficacy is developed over time and through 4 sources of information:
o Personal accomplishments
o Vicarious experiences
o Persuaded by other
o Feeling relaxed and calm
 A person’s cognitive appraisal of how successful or unsuccessful he/she will be has the
greatest impact on the person’s efficacy expectation.
 Perceived self-efficacy – what you believe you can do with your skill
 Self-esteem – a person’s negative or positive sense of self
 Self-efficacy relates to behavior change very directly

Major Assumptions:

1. Individuals make conscious decisions about their behavior. 

2. The extent to which people believe that they can execute a course of action that is required
to succeed is their self-efficacy that motivates their behavior. 
3. Self-efficacy affects individual choice: Choose activities in which you will succeed and avoid
those in which you believe will fail. 
4. Strong self-efficacy increases effort at the task.
5. Strong self-efficacy increases persistence.
6. Strong self-efficacy increases resilience. 
 7. The sources of strong self-efficacy are mastery experiences, modeling (vicarious
experiences), verbal persuasion, and psychological state. 

Motivational Theory

 View change coming from within the person and his/her own motivation to make a change
 Transtheoretical Model (TTM) of intentional change – assesses individual’s readiness to
change and measure progress toward goals over the course of an intervention
 The TTM proposes that effective interventions address an individual’s present stage of
change and cautions that without intervention, individuals may not progress.
 The transtheoretical stages has been applied to variety of health behaviors and system
issues, such as smoking cessation.
 The theory proposes that a person may progress through five stages of behavior (pre-
contemplation, contemplation, preparation, action, and maintenance)
 2 essential elements: 5 integrated stages of change and various processes that can facilitate
a person’s moving from one stage to another

5 stages of change:

1. Pre-contemplation
- Person demonstrate a behavior that is perceived by others as needing to be changed;
can either be harmful or destructive behaviors
- Person might be unaware or aware but fully resistant to acknowledge it
- People who are in the pre-contemplation stage lack awareness to engage in or benefit
from the processes of change
2. Contemplation
- Person is likely to be aware of his/her problem and is thinking about overcoming it but it
not quite ready to take action
- People who reached the contemplation stage are ready to understand the processes
that can contribute to behavioral change
- People may benefit from consciousness-raising strategies that help them to get
information about their problem, by being encouraged to express their feelings through
dramatic relief strategies, such as role playing, by environmental reevaluation to assess
how their behavior affects their physical and social surroundings
3. Preparation
- Person begins to make some small changes in his/her behavior
- Strategies such as values clarification exercises to enhance self-reevaluation, or how one
thinks and feels about him/herself, can be helpful as one moves to the preparation stage
4. Action
- Person is committed to making the change and is involved in change behaviors on a
regular basis
- Making a real commitment to change, believing in one’s ability to change, and using
techniques such as personal goal setting to enhance self-liberation or will power, can be
helpful during action stage
5. Maintenance
- The person struggles to maintain the change, working to sustain accomplishments and
prevent relapse
 - Several processes are important in the maintenance stage, such as fostering helping
relationships and social supports that encourage the person to be open and honest
about his/her problems; avoiding things that elicit the problem behavior and
substituting alternatives (stimulus control and counterconditioning); and reinforcement
management, rewarding oneself for making changes
 The stages of change are occurring in a spiral fashion, because most people experience
relapses or setbacks as they work to change behaviors
 Relapse is expected; can occur back to any stage, however, subsequent progress usually is
easier for the individual
 The processes of change explain how to promote shifts; process of introducing the possibility
of change may allow an individual to risk changing
 Social liberation helps promote change across various stages through advocacy,
empowerment, and social change mechanisms

Motivational Interviewing

 Another clinical process (technique) that encourages people to consider and implement
change

Principles of Motivational Interviewing:

1. Express empathy about the change being considered

2. Develop discrepancy between present behavior and important personal goals and values
3. Roll with resistance by avoiding arguing for change ang inviting new perspectives
4. Support self-efficacy through the person’s belief in the possibility of change

4 Primary skills:

1. Asking open questions

2. Reflective listening
3. Affirming
4. Summarizing
 Therapists should always listen to change talk and elicit the possibility of change talk during
conversation with the client

Six themes of Change Talk:

1. Desire – verbs include want, like, and wish. These tell you something that a person wants
2. Ability – verb is can (could). These show you what the person perceives as within his/her
ability
3. Reasons – words used always express specific reason for a certain change
4. Need – verbs include need, have to, got to, should, ought, and must. These tell you some
necessity
5. Commitment – verbs are will, intend to, and going to. These can be presented with strong or
lower level of commitment
6. Taking steps – reporting recent specific action towards change
 The key to success for this model if the careful, systematic, and close fit between the person,
the stage, and the process
 Efficient self-change depends on doing the right things (processes) at the right time (stages)

Major Assumptions:
 1. Behavior change is a process that unfolds over time through a sequence of stages. Health
population programs need to assist people as they progress over time.
2. Stages are both stable and open to change, just as chronic behavior risk factors are both
stable and open to change.
3. Population health initiatives can motivate change by enhancing the understanding of the
pros and diminishing the value of the cons.
4. The majority of at-risk populations are not prepared for action and will not be served by
traditional action-oriented prevention programs. Helping people set realistic goals, like
progressing to the next stage, will facilitate the change process.
5. Specific principles and processes of change need to be emphasized at specific stages for
progress through the stages to occur.
Summary

 Self-efficacy and motivational theories have great relevance for OT

 A person’s self-perceptions and beliefs about his/her ability to be successful with an
occupation influence the person’s decision about whether to participate in that occupation.
 Intervention stages promote a person’s perceived self-efficacy
 These theories all emphasize the importance of an individual’s participation in meaningful
occupations as both foundation and result of motivation and self-efficacy

Documentation of Practice

- Documentation help us in various ways including, giving home instruction programs to

our clients, as well as their caregivers, or their significant others
- Help inform other professionals, not only OTS, but also doctors, teachers, or PTs

Audience

 The ones that reads our documentation

 As writer of the documentation, we must understand the backgrounds of those audience
 Potential audiences:
o Medical professionals (doctors, nurses, PTs, and social workers)
o Educational professionals (teachers and principals)
o Lawyers (judges)
o Accreditation agencies (Joint Commission, Dept. of Educations)
o Payers (health maintenance orgs)
o Client and client’s guardian
 Each audience reads documentation through a different lens depending on practice setting;
adjust the way you write so that it can be understood by specific audiences
 Professional communication – requires a level of respect and formality
 Informal communication – uses slang and emotionally charged words and directed toward
someone known by the speaker or writer
 Formal documentation – requires compliance with specific standards
 2 important consideration: people form an impression of your professionalism and
intelligence and what you write can be used as an evidence in a court proceeding

Legal and Ethical Considerations

 Legal Consideration
o Health records are legal documents; can be entered as evidence in any type of legal
proceeding involving malpractice, fraud, negligence, or incompetence
  Key ethical issues
o Confidentiality – the ability of the professional to maintain confidentiality in verbal,
written, electronic, and non-verbal communication.
- No discussing of private matters, instead discuss the progress of the client with those
individuals who are also involved in the intervention
- Writing of the initials instead of their full name
o Accuracy & Timeliness – record and report whatever occurrence happened in the
therapy in an accurate and timely manner
- Indicate activities that are done accurately and must be done timely, meaning whatever
indicated should have a date and time
o Compliance – comply with applicable laws, guidelines, and regulations set forth
(PAOT – Phil. Academy of Occupational Therapist)

Importance of Clinical Documentation

 Clinical documentation – involves reporting and interpreting the client’s response on

assessments
 Continuity of care – the intervention or process will continue even if the client transfers to
another OT
 Communication across shifts of disciplines – communicate with other disciplines so we are
aware of what therapeutic activities were performed
 Chronological record of care – awareness of the progress of the client
 Legal record – important document needed for trial
 Reimbursement requirements – health maintenance orgs will require documentation so that
services will be reimbursed
 Objective information should be differentiated from subjective information

Essential Features of All Clinical Documentation

 Date of completion of report Depending on certain institutions:

 Full signature and credentials
 Acceptable abbreviations
 Type of document
 Acceptable terminology
 Client name and case number
 Record storage and disposal
For handwritten documentation:

 Corrections are made with a single line through the error and initials of the individual
making the error above
 No use of erasers or correction tape or fluid
 Black or blue ink

Documentation of the Initiation of OT Services

 The first step is screening of all new admissions to the facility; screening is used to
determine whether or not the person would benefit from an OT evaluation (beginning of the
process and an introduction)
 A short note written to summarize the results of screening/evaluation and indicates the next
step in the intervention process
 Evaluation report (second step)
 o Identifying information – o Occupational profile – client’s
client’s name, age, diagnosis, occupational history,
date of referral, date of experiences, and patterns of
report, and precautions and daily living
contraindications o Findings and results
o Referral information – date (occupational analysis)
and time when the referral o Interpretation of results
was made, and who referred o A plan (goal, frequency,
the client and why duration, and location of
o Evaluation procedures intervention)
o Signature and credentials

 Evaluation reports are written by OTs to document the starting point of intervention; based
on the OT Practice Framework 2nd Edition
 Summarizes and indicates the next process; contain factual data collected
 Initial plan of care (care plan, intervention plan) includes measurable, functional, and time-
limited goals; based on the occupational profile and occupational analysis

Documentation of Continuing OT Services

 Depending on the setting (not only in clinical settings)

 Progress notes/ clinical notes of the activities, observations, and interventions are written
after each intervention (per day/per session)
 Written in a narrative or SOAP Note
o S: Subjective – contains subjective experience of the client; important to be able to
identify the problems of the client
o O: Objective – OTs objective observation and measurement during intervention;
write down the observations during the intervention/treatment
o A: Assessment – interpretation of the OTs of the meaning of the objective part
o P: Plan – description of what will happen in the next therapy session
 A progress report is written to document progress over time
 An updated plan of care is written in which clients are seen for an extended period of time;
updates the short-term goals and sets new ones (long-term goals remains the same)

Documentation of Termination of OT Services

 If the client is able to achieve long-term goals, he/she can now discontinue the OT service
 A discontinuation summary is written that includes:
o Client identification and background information
o Summary of the client’s functional status at the initiation of OT services
o Summary of change in the functional status at the close of OT service – comparison
of the status at the beginning and at the end
o Results of outcome measures
o Recommendations for follow-up
o Signature, credentials, and date
 Outcomes are reflected in subjective (client reports) and objective (from standardized and
non-standardized testing) data gathered

Electric health records

  Replacing paper charts in practice settings; requires health care providers to enter clinical
data into a computerized system (laptops, tablets, smartphones)
 Allows instant access to updates information about client’s health care; needs special
precautions
 Employees receive excessive trainings and policies to protect client confidentiality

Advantages and Disadvantages:

Advantages Disadvantages
Legibility Less flexible in content
Speed (one click) Investment in time and money
Automatic entry of client info Learning curve required to develop proficiency
Accessible by anyone on the team Need for staff training and continuous updates

Documentation in School Settings

 Use of notice and consent forms, Individualized Family Service Plan (IFSP), and Individualized
Education Program (IEP)

Documentation of Notice and Consent

 Notice and consent are required to communicate with parents/guardians

 Documents may include notices of team meetings, referral for an initial evaluation, and
procedural safeguards

Documentation of Services from Birth through Age 2 years

 IFSPs are written to address these services

 Designates a lead agency (education, health, or human services) to serve the needs of
infants and toddlers
 OTs can be service coordinator – responsible for ensuring that proper documentation is
completed
 IFSP includes:

o Summary of child’s present level of performance (physical, cognitive,

communicative, and social or emotional)
o Identification of the family’s concerns, and resources
o Identification of early intervention services needed, included frequency, intensity,
and service delivery method
o Date services started and length of services
o Identification of a service coordinator for the child
o Steps that will be taken to help the toddler transition to preschool setting

Documentation of Services from Age 3 – 21 Years

 IEP is the document the guides services for a child with disabilities; may include both special
education and related services (occupational therapy services)
 Would not serve as a service coordinator but would contribute to the process of writing and
revising the IEP (written every year, reviewed every 6 months)
 IEP includes:
o Present level of educational performance & Participation with nondisabled children
 o Annual goals and Special education and related services
o Starting date and location of services
o Transition services & Measurement of progress
 The fundamental difference of IFSP and IEP is that IFSP is more holistic; can address a
broader range of needs. An IEP must be educationally related

Documentation is Emerging Practice settings

 Advisable to develop eval, intervention plan, progress, and discontinuation reports (new
program); provide the agency with periodic consultation reports with less structured format
(community or population level)
 Consultation reports are narrative descriptions of the needs of assessments, plan, and
outcomes
 Use of documentation as a mechanism to demonstrate successful outcomes

Administrative Documentation

 OTs write n incident report, grant proposal, policies, and procedures. (administrative
documentation because they are necessary for ongoing administration of OT service)
 Policies and Procedures must be written clearly that all employees must understand
 Administrative documentation requires use of terminology that anyone can understand

Tips in Documentation

 Use correct word choice, grammar, syntax, spelling & Be precise

 Avoid slang & Write legibly
 Proofread

Conclusion

 Occupational therapy documentation should adhere to professional ethical guidelines and

practice standards.
 It is the practitioner’s responsibility to be aware of and comply with all documentation
requirements.