DOCUMENTATION IN OT 2) Communicability

TYPES OF RECORDS - Records should be clear and

 Clinical Records communicable because this
- Patient care (ex.: OT notes, referral will be shared to doctors,
notes, assessment notes) teachers, etc.

 Administrative or Departmental Records 3) Standardization

- Statistical records, personal - Achieve consistency which
management records, equipment supply is essential for comparison
records, financial records - Ex.: evaluation and re-
evaluation uses the same
PURPOSE format to see the difference/
 Provide legal, serial record of client’s improvements/ problems
condition (legal document) solved
 Information resource for client care to
facilitate effective interventions 4) Form development and design
 Communicate information about client - Ex.: color, sizes, font style of
from OT perspective (can be used when a the paper must be consistent
patient or client transfers to another OT)
 Provide data for use in intervention ,
evaluation, research and education (this will 5) Ownership and Retention
be used as a proof for reimbursement to - All records are owned by
their insurance clinic and cannot be released
without permission
PURPOSES OF RECORD KEEPING
 For betterment of patient care Documentation in Clinical Settings
 Education In hospitals we have rehabilitation facilities, out-
 Communication (OTs to parents, OTs to patient clinics, mental health centers, and home
OTs) health. Similar types of documentation are used
although the frequency of documentation may vary.
 Third party payers, reimbursement
 Social benefits (Ex. SSS)
In clinical documentation, it generally involves
 Legal aspects
reporting and interpreting a client's response/s or
 Research
assessments in interventions in a medical record.
 Motivation tool These are the things that must be seen in a
 Administrative control document in an OT practice.

AUDIENCE ● Date of completion of report

1. Medical Professionals ● Full signature and credentials (of the OT)
2. Education professionals ● Type of document (if its OT notes, initial
3. Accreditation agencies evaluation)
4. Payers (Insurance companies) ● Client name and case number on each
5. The client/caregivers page (not just in the first page)
● Acceptable abbreviations as determined by
CONTENTS the facility
1) Function and purpose ● Acceptable terminology as determined by
- records should be clear and the facility (always follow the uniform
purposeful terminology and abbreviations in OTs)
- for OT notes, it’s to record
the activities per session
 ● Corrections made with a single line ● Evaluation procedures and/or test used
through the error and initials of person ● Occupational profile (the client’s perception
who made the error are written above of the need for occupational therapy. The
● No use of an eraser or correction tape or context that supports or hinder occupational
fluid performance or brief history of Occupation)
● Record storage and disposal that complies ● Findings or results of the evaluation process
with federal and state laws and facility ● An interpretation of the meaning of the
procedures findings or results that reflects the
● Protections of confidentiality (we are not occupational needs of the client
allowed to put other client’s name sa ● A plan, including goals, frequency, duration,
patient’s document, bali dapat name rajd sa and location of intervention
tagiya anang document ang naa) ● Signature and credentials of the
● Black or blue ink, never pencil (Sames, occupational therapist (printed name of the
2005) - this applies to hand written notes OT and licensed number)

Documentation of the Initiation of Occupational Documentation of Continuing OT Services

Therapy
● Screening - if the client is seen for  Progress notes - these are used
screening or introduction prior to an periodically to document the
evaluation, a short note is usually written in interventions, progress towards functional
the medical records summarizing the goals, into updating of the goals and
conversation and the results of the interventions/ treatment plan.
screening. (In abroad, it's the OT assistant
who is usually taking down the notes but  Clinical notes/OT notes - these are used
here in the PH, it's the direct OTs are the to document individual occupational
one doing it) therapy sessions. It’s usually written after
each intervention session
● Evaluation - this is written by the OTs to
document the starting point of the One of the most common forms of documenting the
Occupational therapy intervention and it client’s progress is through the “S-O-A-P” notes.
contains factual data collected during the S - Subjective (experience of the client)
evaluation process and the interpretation of O - Objective (OT’s objective, observation and
the evaluation findings. measurements)
A – Assessment (Clinician’s interpretation of the
There is a need to document the OT services meaning of O-Section)
before interventions can be implemented. P – plan (Plan description of what will happen next)
The very first evaluation is initial evaluation nya
mao to di nalng ko mo discuss unsay sulod ani Soap notes is a practice the strengthens the
pero ang initial evaluation will take place first communication of the OT professionals
before the treatments begin and is the
foundation of selecting treatment objectives ● RUMBA (Relevant, Understandable,
and methods. It also identifies the performance Measurable, Behavioral, Achievable)
areas and components. ● POMR (Problem-Oriented Medical Record)
- SOAP
Typically, the evaluation report contains the - BIRP (Behavior, Intervention, Response,
following: Plan)
● Identifying information and background
information
● Referral information
 Documentation of Discontinuation of Attainable: how much time you have with the client
Occupational Therapy along with their current level of functioning

Two types of documentation in discontinuation: Realistic: be realistic in approaching the goals of

the client, do something the client can actually
● ENDORSEMENT NOTES achieve
- Used to document client’s basic
information, the problems and Time-Bound: certain time for the goal
improvements for the continuation of
treatment.
- made for the next OT if ever the  ABCD (Audience, Behavior, Condition,
client transfers. Degree)
- Content: - Audience: performer
(1) name, age, sex, address, (5) the - Behavior: desired functional
referral source and the services behavior to be demonstrated or
requested, (6) the problems list, (7) increased as outcome of
the management and activities that intervention
were given during the past OT - Condition: circumstances under
sessions, (8) list of improvements behavior must be performed
and progress after a number of - Degree: time period goal to be met
treatment sessions, (9) the - Ex: The child (audience) will be able
recommendation from the past OT to to eat (behavior) using a spoon
the next therapist. without difficulty (condition) within 8
weeks of the OT session (duration).
● DISCHARGE NOTES
- These documents are used as a  CARE (Clarity, Accuracy, Relevance,
summary of the course of therapy Exceptions)
and any recommendations. - Not usually used in the Philippines
- Content: therapy process, goal and other places but there are still
attainment, the functional outcome OTs that will use this format.
of the client’s interventions
(summary of the client’s functional GUIDELINES
status at the initiation of the ➔ Legible handwriting (prefer handwritten than
occupational therapy services, from encoded).
the very first intervention to the ➔ Correct grammar and spelling
last), recommendations for follow- ➔ Be concise, but complete, non-important
up, home instructions program, and details should be left out.
the signature, credentials and the ➔ Be objective with clear distinctions between
date of the OT. facts vs behaviors and opinions vs
interpretations (the therapist should not be
OTPF (GOALS) biased, be more objective and more aware
 SMART (Specific, Measurable, Attainable, of our opinions vs interpretations/
Realistic, Time-bounded) observations).
➔ Be current and accurate, active rather than
Specific: tangible outcome, what does client want passive voice.
to do ➔ Use first person language at all times (ex:
child with autism or child with a mental
Measurable: essential in reimbursement as this will
disorder).
track the progress and gives concrete data on the
client’s performance