How to document care plan conference occupational therapy


What is an example of documentation in occupational therapy?

Documentation Guidelines. For example, an OT will create a plan of care, which is a detailed plan of the treatments the OT will provide a patient and the ultimate goal of the treatments. It is important for an OT to document when a patient reaches the goal of the plan of care.

What is included in the plan of care for Occupational Therapy?

Plan of care Recommend skilled OT services 1x/week consisting of therapeutic exercises, therapeutic activities, ultrasound, phonophoresis, e-stim, hot/cold therapy, and manual techniques. Services will address deficits in the areas of grip strength and range of motion, as well as right hand pain.

What time of day should an occupational therapist document?

Ideally, an OT should document immediately after each therapy session. However, OTs can often get very busy, and sometimes they see patients back to back. In these situations, OTs may need to complete documentation later that evening or the next morning.

Why is it important to document your occupational therapy sessions?

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.


How do you document an OT note?

Occupational Therapy Documentation: a Few GuidelinesIf You Didn’t Write It Down, It Didn’t Happen. … Don’t Go Overboard with Details. … Specific Observations. … Arguments and Hard Evidence. … Don’t Overdo Jargon. … Be Specific About Patient Improvement. … Note Non-Treatment Interactions Too. … Fill in Documentation in a Timely Manner.

What is plan of care in occupational therapy?

The plan of care shall contain, at minimum: – Diagnoses, – Long term treatment goals, – Type, amount, duration and frequency of therapy services.

What are the 5 domains of OT?

These domains are:Occupations.Performance patterns.Performance skills.Environment and context.Client factors.

What are the 3 steps to the occupational therapy process?

There are three main steps to the occupational therapy process: evaluation, intervention, and outcomes.

What are the Aota official documents?

Guidance Documents (previously Guidelines)Guidelines for Documentation of Occupational Therapy (2018)Guidelines for Occupational Therapy Services in Early Intervention and Schools (2017)Guidelines for Reentry Into the Field of Occupational Therapy (2020)More items…

What should be included in an OT evaluation?

Occupational therapy (OT) treatment begins with an evaluation….Client Interview and Information GatheringAge.Referring Physician.Past Medical History.Reason for Referral.Diagnosis.Precautions.

How does occupational therapy contribute to discharge planning?

The main role of the OT in the acute care setting is to assist in discharge planning and providing shortened, functional interventions when possible. This means the OT helps the doctors and case managers determine if a patient is safe to go home and, if not, treats the patients where appropriate.

How long are therapy referrals good for?

A: A referral is good for 90 days from the date of issue. If a service is required beyond 90 days, a new referral must be issued by the PCP.

What are the 7 core values of occupational therapy?

The profession is grounded in seven long-standing Core Values: (1) Altruism, (2) Equality, (3) Freedom, (4) Justice, (5) Dignity, (6) Truth, and (7) Prudence. Altruism involves demonstrating concern for the welfare of others. Equality refers to treating all people impartially and free of bias.

What are performance patterns in occupational therapy?

Performance patterns are the acquired habits, routines, roles, and rituals used in the process of engaging in occupations and can support or hinder occupational performance.

What are client factors OT?

Client factors include (1) values, beliefs, and spirituality; (2) body functions; and (3) body structures that reside within the client that influence the client’s perfor- mance in occupations.

Which of the following is the correct order of the occupational therapy process?

The evaluation process includes referral, screening, developing an occupational profile, and analyzing occupational performance. The intervention process includes intervention planning, implementation, and review.

What are the five general treatment approaches used in OT practice?

What are the five general approaches to intervention? Therapeutic use of self, therapeutic use of occupation or activity, preparatory methods, consultation, or education. The OTPF provides a description of the occupational therapy domain and process for OT practitioners, students, and consumers.

What is the Moho model in occupational therapy?

The Model of Human Occupations (MOHO) is a model that describes how humans generate and modify their occupations in interaction with environment, which presents a dynamic open cycle system of human actions.

What is the meaning of Aota?

AOTA means the national professional association representing the interests and concerns of occupational therapy practitioners and students and improve the quality of occupational therapy services. Sample 1Sample 2. AOTA means the American Occupational Therapy Association, Inc.

What is telehealth Aota?

Telehealth resources provide guidance, education, and information to occupational therapy practitioners who have an interest in providing services remotely.

What is Aota’s Vision 2025?

Vision 2025 As an inclusive profession, occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living.

What does a typical occupational therapy session look like?

A Typical Session We do a combination of fine motor and sensory activities that may include table-top activities (craft projects, writing, dexterity, coordination, and visual motor or visual processing activities) and working on specific goals or the skills required for a goal in an IEP or similar.

What assessment tools do occupational therapists use?

Common Assessment Tools in OT:Adolescent/Adult Sensory Profile.Assessment of Motor and Process Skills (AMPS)Back on Track.Bayley Scales of Infant Development (BSID)Berry-Buktenica Developmental Test of Visual-Motor Integration (BEERY VMI)Developmental Test of Visual Perception (DTVP-2)More items…

What is an OT sensory assessment?

The Sensory assessment is an assessment that can take place in clinic, at home or in school. It will be completed by an occupational therapist through an observation of the behaviours and movements the child shows in relation to the sensory input they are receiving.

What are the domains of the Nbcot exam?


What is domain in occupational therapy quizlet?

What are the 5 Domains of Occupational Therapy? Occupations, Client Factors, Performance Skills, Performance Patterns & Contexts and Environments.

What are the areas of occupation?

There are 8 areas of occupation that OTs are trained in:Activities of daily living (ADLs)Instrumental activities of daily living (IADLs)Sleep and rest.Work.Education.Play.Leisure.Social participation.

What is an occupational profile?

“The occupational profile is a summary of a client’s (person’s, group’s, or population’s) occupational history and experi- ences, patterns of daily living, interests, values, needs, and relevant contexts” (AOTA, 2020, p.

Why is documentation important in occupational therapy?

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.

Why is documenting important?

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.

When is documentation for occupational therapy 2021?

February 11, 2021. If you are an occupational therapy practitioner you know all about the dreaded “d” word called documentation. It’s part of the daily life of a therapist, and it can sometimes seem like it’s all we do. Let’s break down this dreaded task with some occupational therapy documentation tips and look at the positive side …

Why is daily documentation important in occupational therapy?

Daily documentation (along with the dreaded productivity) is not the most fun or anticipated aspect of the occupational therapy profession, but it is a necessary part of it in order to fully appreciate and understand the need for our service and determine if it is making a difference in our client’s life.

What is a soap note in occupational therapy?

Occupational therapy SOAP notes cover all aspects of documentation using an easy to remember acronym. Most therapy practitioners utilize the SOAP note format developed by Lawrence Weed, M.D. which originated from his original problem-oriented medical record.

Subjective (S)

Each note should tell a story about your patient, and your subjective portion should set the stage.

Objective (O)

The objective section of your evaluation and/or SOAP note is often the longest. This is almost certainly the case in an evaluation.

Assessment (A)

The assessment section of your OT note is what justifies your involvement in this patient’s care.

Plan (P)

I once went to a CEU course on note-writing, and the course was geared toward PTs.

More resources for improving your documentation

I recognize that defensible documentation is an ever-evolving art and science, and have come across many useful resources that will help you keep your notes complete, yet concise. I highly recommend the following:


Documentation can get a bad rap, but I believe that OT practitioners are uniquely poised to write notes that are meaningful to other healthcare practitioners and patients alike.

Why do occupational therapists need documentation?

Documentation helps prove that an occupational therapist actually provided treatment to a patient. For example, insurance companies base their reimbursements and payments on documentation. If a treatment or procedure isn’t documented, an insurance company won’t pay for it.

What are the parts of occupational therapy?

There are four main parts of occupational therapy: screening, evaluation, intervention, and outcomes . It’s really important for an OT to document all that is performed on a patient in all four of these areas.

What is the intervention plan in a note?

It describes the plan for the patient interventions, or the forms of treatment the patient will receive over the course of skilled therapy to achieve the anticipated goals/short term goals established in the initial evaluation.

What to include in an intervention plan?

The following are also frequently included in the Intervention Plan section of the initial evaluation note: 1 Patient and family education (e.g., home exercise program; if provided, attach a copy of any home exercise program [s] [signed and dated, of course] to the health record) 2 Any equipment for which the patient and/or his caregiver has been educated 3 Any equipment recommended …


A New Perspective on Documentation

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. 1. 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 ti…

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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: 1. Name 2. Date of birth 3. E…

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  • DO use the subjective part of the note to open your story
    Each note should tell a story about your patient, and your subjective portion should set the stage. Try to open your note with feedback from the patient about what is and isn’t working about their therapy sessions and home exercise program. For example, you can say any of the following to …
  • DON’T go overboard with unnecessary details
    Let’s admit it: we are storytellers, and we like to add details. But, we must admit we’ve all seen notes with way too much unnecessary information. Here are a few things you can generally leave out of your notes: 1. “Patient was seated in chair on arrival.” 2. “Patient let me into her home.” 3. “…

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  • DO go into detail about your observations and interventions
    The objective section of your evaluation and/or SOAP note is often the longest. This is almost certainly the case in an evaluation. This section should contain objective measurements, observations, and test results. Here are a few examples of what you should include: 1. Manual …

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  • DO show clinical reasoning and expertise
    The assessment section of your OT note is what justifies your involvement in this patient’s care. What you’re doing in this section is synthesizing how the story the patient tells combines with the objective measurements you took (and overall observations you made) during today’s treatmen…
  • DON’T skimp on the assessment section
    The assessment section is your place to shine! All of your education and experience should really drive this one paragraph. And yet… We tend to just write: “Patient tolerated therapy well.” Or we copy and paste a generic sentence like this: “Patient continues to require verbal cueing and will …

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  • DON’T get lazy
    I once went to a CEU course on note-writing, and the course was geared toward PTs. It felt to me like most of the hour was spent talking about how important it is to make goals functional. But we OTs already know this; function is our bread and butter. So, why do many OTs insist on writing th…
  • DO show proper strategic planning of patients’ care
    This section isn’t rocket science. You don’t have to write a novel. But you do need to show that you’re thinking ahead and considering how your patients’ care plans will change as they progress through treatment. Consider something like this: “Continue working with patient on toileting, whil…

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General Do’s and Don’ts For Documentation

  • Your patient is the hero—and you are the guide. In every good story, there’s a hero and a guide. The patient is Luke Skywalker, and you are Yoda. I think as therapists, we tend to document only one part of the story. For example, we focus on the hero’s role: “Patient did such and such.” Or we focus on what we, the guide, bring with our skilled interventions: “Therapist downgraded, correct…

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Example Outpatient Occupational Therapy Evaluation

  • Name:Phillip Peppercorn MRN: 555556 DOB:05/07/1976 Evaluation date: 12/10/18 Diagnoses: G56.01, M19.041 Treatment diagnoses:M62.81, R27, M79.641 Referring physician: Dr. Balsamic Payer:Anthem Visits used this year:0 Frequency: 1x/week

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More Resources For Improving Your Documentation

  • I recognize that defensible documentation is an ever-evolving art and science, and have come across many useful resources that will help you keep your notes complete, yet concise. I highly recommend the following: 1. The Seniors Flourish Podcast: Simplify Your Documentation (five-part series) 2. WebPT: Defensible Documentation Toolkit(download required) 3. The Note Ninjas…

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  • Documentation can get a bad rap, but I believe that OT practitioners are uniquely poised to write notes that are meaningful to other healthcare practitioners and patients alike. It seems inevitable that our patients will gain easier access to their notes over the next decade, and when they do, I want our documentation to stand out as relevant and useful. This article is meant to evolve over …

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