Occupational Therapy Documentation Tips for Any Setting

As a new occupational therapist or OT student, documentation can be difficult to get the hang of. It can seem so overwhelming thinking of all the interventions, observations, inferences, and more that occur during each and every minute of a patient session.

For this reason, a lot of students (and even practicing therapists!) overthink documentation and feel the need to write massive notes that include every detail down to the color of the patient’s shirt. The good news is that occupational therapy documentation is actually best when it’s kept super simple. To help with this, be sure to follow these occupational therapy documentation tips when writing any kind of documentation. Note that these tips are applicable to any OT setting.

Include Medical Necessity

One of the most important parts of documenting is understanding the concept of medical necessity. Medical necessity is a fancy way of saying whether a patient’s treatment is happening for a legitimate reason. Some facilities ask therapists to include a clear statement of medical necessity.

If you’ve reviewed an occupational therapy note before, you may be familiar with wording like: “This indicates that Mrs. Smith demonstrates the continued need for skilled occupational therapy services.” If you’re reading an evaluation, it may look more like: “The findings in this evaluation report point toward a need for skilled occupational therapy services to remediate deficits in XYZ.”

Regardless of how these statements look, they are intended to make everyone – other clinical staff and even people without a medical background – understand why the patient is seeking help and what concerns they have that an OT can help with.

Medical necessity doesn’t just exist for OTs. Every clinical profession needs to document this need. Otherwise, insurance companies are likely to deny reimbursement.

For example, a patient staying in a skilled nursing facility may have a complicated wound that requires the application of a wound vacuum with adjustments made two to three times each day. This is something that cannot be done at a lower level of care, which is an outpatient clinic or through a home health agency. In this situation, clinicians will document that the patient still needs this equipment (which is usually only available in residential facilities) to minimize the risk of infection, reduce the risk for rehospitalization, and allow for effective wound healing.

On the other hand, if a patient has a surgical incision that requires a dressing change with gauze once per day, this is something that can be done by a home health aide or even a caregiver who lives nearby. A patient would not need a bed in a skilled nursing facility to comply with this care recommendation.

Always Add Assist Levels

By now, you probably know that assist levels are the way we as OTs measure progress in nearly every patient care setting. Assist levels let you know how independent a patient is and, when compared to a patient’s prior level of functioning (PLOF), it tells you when they may be ready for discharge.

Say you see an older patient in the hospital for a minor infection. You read their chart and they previously needed total/complete assistance for all of their ADLs and also have a live-in caregiver. This gives you an idea of what sort of intervention you would focus on. If you are unable to provide any self-care training to the patient due to their deficits, you will want to focus on giving them enough support in the home.

So you’d emphasize caregiver training, the use of durable medical equipment (DME) by either ordering it or making adjustments to existing equipment. If your evaluation didn’t mention a prior level of function but your notes mention that the patient is dependent for all ADLs, a therapist who picked up this case may think that the patient needs to enter more rigorous rehabilitation before returning home.

So, it’s key to mention assist levels both in the evaluation and within each note, since this gives everyone a good view of improvements that have been made or plateaus that are becoming visible.

Quantify Your Notes

Occupational therapists don’t always love math, numbers, and other figures – though some with this strength end up doing so in research-based settings! But adding some numbers into your notes is a good idea whenever possible.

What does this mean? If you are doing a ball toss activity with a patient and you wanted them to take 10 shots before you move on to something else, you would likely document how many shots they made. Your note might say something like: “Patient completed 7/10 trials of dynamic balance activity in standing with good safety awareness and tracking skills.”

Quantifying your notes is a helpful way to demonstrate progress. This not only helps you know how a patient “scored” on an activity from session to session, but it also lets you more easily take mini-assessments throughout your time with a patient. Insurance companies like seeing this type of information in notes because it’s objective and easy for them to understand. They don’t have to have a clinical background of any kind to know that 4/5 is an improvement from 1/5 and so on.

Use Universal Abbreviations

The medical field is known for its alphabet soup. Notes are often chock full of credentials, acronyms, and abbreviations. While there are a lot of universal abbreviations out there, don’t get too overwhelmed. The greater majority of those that pertain to you become second-nature, like BUE for bilateral upper extremities and ADL for activity of daily living.

A good rule of thumb is to avoid using any abbreviations unless you’re certain you know what they mean. This is not only good for your own reputation and reliability, but it also guarantees that others reading your notes will be able to comprehend them. Abbreviations can also be very helpful in keeping your notes short and to-the-point.

Conclusion

Whether it’s a daily note or an evaluation report, occupational therapy documentation doesn’t have to be excessively verbose with a lot of fluff. Unlike school assignments, there is no minimum word count or a page requirement to fulfill. For this reason, you should do your best to make all of your daily OT notes as concise as possible.

Most healthcare settings, especially skilled nursing facilities, outpatient clinics, and hospitals, use a SOAP note format (check out our SOAP note guide here). SOAP notes encourage 1-2 sentences for each aspect of the note (subjective, objective, assessment, and plan). There is no need to link the sentences or worry about transitions. Simply comment on the areas you need to (while keeping the above tips in mind) and you’re done.

As for settings like mental health facilities, narrative format is often indicated, so there will need to be some flow but there is no defined structure or format to follow as there is with SOAP notes. School-based settings also follow the general SOAP note format, but evaluation reports will usually vary based on templates assigned by the school.

Across all settings, just remember one thing: don’t over-complicate your notes. Stick to the patient’s disposition at the start of the session, the interventions you provided, patient responses to those, note the remaining deficits (medical need), and you will be good to go!

What part of OT documentation do you find most complicated? What other tips would you share? Let us know in the comments!

Need more help with OT documentation?

Be sure to check out our favorite guides here. Purchases made may result in a small commission for us at no additional cost to you, and all proceeds go directly back into My OT Spot operating costs.

Seniors Flourish: OT Goal Writing & Goal Bank

Seniors Flourish: Goal Writing Workbook

The Note Ninjas ADL Treatment Guide