Documentation

DOCUMENTATION IN
OCCUPATIONAL
THERAPY
Vinodhini.C
Occupational Therapist
July 26, 2018 1

Overview:
• Defining documentation
• Purpose of documentation
• Elements of documentation
• Do’s and don’t’s of documentation
• Clinical reasoning in documentation
• Types of occupational therapy documentation
• Types of Documentation Reporting Formats
• Confidentiality and Documentation
• Legal liability
• Best terminology
• Abbreviations
• Supporting evidence
July 26, 2018 2

Objectives:
• Identify the purposes of documentation
• Important elements of documentation
• What are the types of occupational therapy documentation
• What SOAP Notes, RUMBA and SMART refers to.
• What are the types of Documentation Reporting Formats
• Why is confidentiality important in documentation and its governing body
• What is the legal importance of documentation
July 26, 2018 3

Defining documentation:
General definition:
• Material that provides official information or evidence or that serves as a record.
(Oxford dictionary)
Occupational therapy definition:
• Documentation is a permanent record of what occurred with the client.
Documentation is an ongoing process that continues throughout the client’s therapy
program. Screening reports, initial evaluation reports, re-evaluation reports,
progress notes, discharge summaries, other medical record entries, intervention and
equipment authorization requests, letters and reports to families and other health
care professionals, and outcomes data collection are examples of places where
occupational therapists document.
July 26, 2018
Pendleton HM, Schultz-Krohn W. Pedretti's Occupational Therapy-E-Book: Practice Skills for Physical Dysfunction.
Elsevier Health Sciences; 2017 Mar 10.
4

Purpose of documentation:
o AOTA has identified that the purposes of documentation are as follows:
• Articulate the rationale for provision of occupational therapy services and the
relationship of this service to the client’s outcome
• Reflect the therapist’s clinical reasoning and professional judgment
• Communicate information about the client from the occupational therapy
perspective
• Create a chronological record of client status, occupational therapy services
provided to the client, and client outcomes
July 26, 2018 5

Elements of documentation:
1.Client’s full name and case number.
2. Date and type of occupational therapy contact.
3. Identification of type of documentation, agency, and department name.
4. Occupational therapy practitioner’s signature with a minimum of first name or
initial, last name, and professional designation.
5. When applicable on notes or reports, signature of the recorder directly at the end of
the note and the signature.
6. Countersignature by an occupational therapist on documentation written by
students and occupational therapy assistants when required by law or the facility.
July 26, 2018
Date from American Occupational Therapy Association (AOTA):
Guidelines to the occupational therapy code of ethics, Am J Occup Ther
60:652-658, 2006.
6

Contd.
7. Acceptable terminology defined within the boundaries of the setting.
8. Abbreviation usage as acceptable within the boundaries of the setting.
9. Adherence to professional standards of technology, when used to document
occupational therapy services.
10. Disposal of records within law or agency requirements.
11. Compliance with confidentiality standards.
12. Compliance with agency or legal requirements of storage of records
July 26, 2018
Date from American Occupational Therapy Association (AOTA):
Guidelines to the occupational therapy code of ethics, Am J Occup Ther
60:652-658, 2006.
7

Do's and Don'ts of Documentation: Tips From OT
Managers
• Participants of AOTA’s Leadership Development Program for Managers to weigh
in with their best documentation advice
• Documentation Do’s:
• Do highlight the distinct value of OT in each and every note you write
• Do write legibly. A legible and effective narrative means that others can access
the information with ease
• Do be timely. Try to document in real time (or very soon after) to accurately
report events
• Do write it down. Documentation that happens today is future evidence of the
quality of care or of the intervention the client received.
July 26, 2018https://www.aota.org/Practice/Manage/Reimb/documentation-dos-donts-tips-from-OT-managers.aspx 8

Contd.
• Do document non-treatment client interactions in the client’s chart/electronic
medical record, including phone calls—both to the client or other care providers
regarding the client’s care—and cancellations or reports sent on behalf of the
client.
• Do document specific functional areas of improvement seen and tie that to
occupation such as changes in assistive devices or changes in progression of skills
• Do make every note individualized, including making every goal and treatment
session client-centered. Include client comments and goals.

Contd.
• Documentation Don’ts
• Don’t treat your documentation like the kitchen sink and fill it full of unnecessary information
and do not be so generic in your documentation that you do not display your skill (or unique
value as an OT).
• Don’t establish too many goals. Consider the realistic time-frame that you have with your
client and focus on his or her priorities.
• Don’t use jargon or slang. Unclear terms, poor spelling, or unapproved abbreviations can cause
confusion.
• Don’t be vague and assume the reader understands what you are writing.
• Don’t only document a list of what interventions were provided to a client. Include your
observations of how clients responded to each intervention, any cueing that you provided and
how the interventions chosen will assist the clients in meeting a functional goal.

Clinical reasoning in documentation:
• Clinical reasoning is the process used by occupational therapists to plan, direct,
perform, and reflect on client care.
• Choosing appropriate assessments based on an understanding of the client’s
diagnosis and the areas of occupation that might be affected.
• Clinical reasoning are used to identify, analyze, interpret, and document
performance components that may contribute to the client’s engagement in
occupations.
• Terminology used in documentation should reflect the unique skilled services
that the occupational therapist uses to address the client.
July 26, 2018
11

Systems of occupational therapy documentation:
July 26, 2018 12
Initial evaluation
Intervention plan
Progress report

Initial evaluation:
• Evaluation is the process of obtaining and interpreting data necessary for
understanding the individual, system, or situation.
• It includes planning for and documenting the evaluation process, results, and
recommendations, including the need for intervention.
• The evaluation should include an occupational profile of the client.
• Assessments are the tools, instruments, and interactions used during the evaluation
process.
• These include standardized and non-standardized tests.
• They can be written tests or performance checklists. Interviews and skilled
observations are examples of assessments frequently used in the evaluation process.
July 26, 2018
13

Components of evaluation report:
• The evaluation report should contain the following information:
1. Client information: name/agency; date of birth; gender; education, and
developmental diagnosis; precautions; and contraindications
2. Referral information: date and source of referral; services requested; reason for
referral; funding source; and anticipated length of service
3. Occupational profile: client’s reason for seeking occupational therapy services;
current areas of occupation that are successful and areas that are problematic;
contexts that support or hinder occupations; medical, educational, and work
history; occupational history; client’s priorities; and targeted outcomes
July 26, 2018
14

Contd.
• 4. Assessments: types of assessments used and results (e.g., interviews, record
reviews, observations, standardized or non-standardized assessments)
• 5. Analysis of occupational performance: description and judgment about
performance skills; performance patterns; contextual or environmental aspects or
features of activities; client factors that facilitate or inhibit performance; and
confidence in test results
• 6. Summary and analysis: interpretation and summary of data as they relate to
the occupational profile and referring concerns
• 7. Recommendation: judgment regarding appropriateness of occupational
therapy services or other services
July 26, 2018
15

Intervention plan:
• Upon completion of the assessment, the intervention plan is established.
• Problem statements should include a description of the underlying factor and its
impact on occupations.
• Goals must be measurable and directly related to the client’s ability to engage in
desired occupations.
• The client intervention plan contains both short- and long-term goals.
• Some therapists prefer to use the term objective in place of short-term goal. Short-term
goals or objectives are written for specific time periods.
• Long-term goal, which is also called the discharge goal in some settings. The long-term
goal is generally considered to be the overall functional goal of the intervention
plan.
July 26, 2018
16

Progress reports:
• Progress toward goal attainment is an expected criterion for reimbursement of
occupational therapy services.
• Documentation demonstrates progression toward goal achievement.
• The purposes of the progress report are to document the client’s improvement,
to describe the skilled interventions provided, and to update goals.
• Progress reports can be written daily or weekly depending on the requirements
of the work site and the payer source.
July 26, 2018
17

Source-Oriented Medical Record (SOMR)
• The more traditional format used for recording data in the medical record is the
source-oriented medical record (SOMR).
• History and Physical, Progress Notes (notes that track the patient’s progress),
Nursing/Medical Assisting Notes, Laboratory, and Diagnostic Testing.
• The “source” or individual providing the data enters the information within the
appropriate section of the chart
July 26, 2018 18

Problem oriented medical records:
• The POMR as initially defined by Lawrence Weed, MD, is the official method of
record keeping.
• The basic components of the POMR are:
1. Data Base - History, Physical Exam and Laboratory Data
2. Complete Problem List
3. Initial Plans
4. Daily Progress Note
5. Final Progress Note or Discharge Summary
Formats: SOAP notes, RUMBA and SMART
July 26, 2018 19

Types of progress notes:
SOAP notes
Narrative notes
Descriptive notes
Progress checklist/flow sheets
RUMBA
SMART
Discharge reports
July 26, 2018
20

SOAP Notes:
• The SOAP note format was first introduced by Dr. Lawrence Weed in 1970 as a
method of charting in the problem-oriented medical record (POMR).
• Each letter in the acronym SOAP stands for the name of a section of the note:
• S = Subjective
• O = Objective
• A = Assessment
• P = Plan
July 26, 2018
21

Subjective section(S):
• The subjective (S) part of the note is the section where the therapist includes information
reported by the client, family or caregivers .
• Information that the client gives about the current condition, is appropriate to include in the
section.
• Client’s subjective response to treatment is recorded in this section.
• Direct quotes can be used when appropriate.
• The Subjective section should include only relevant information, avoid statements that can be
misinterpreted or not useful.
• Negative quotes from the client that do not relate to the intervention session are not necessary.
• If there is nothing relevant to report in the Subjective section, it is permissible to not include a
statement.
July 26, 2018
22

Objective section(O):
• In the Objective (O) section of the SOAP note, the therapist documents the results
of assessments, tests, and measurements performed, as well as objective
observations.
• Data that are recorded in the Objective section are measurable, quantifiable, or
observable.
• Only factual information must be included.
• Results of standardized and non-standardized tests are documented in this part
of the note.
• Objective section can be organized categorically. Information that is organized
categorically should follow the categories outlined in the Occupational Therapy
Practice Framework
July 26, 2018
23

Assessment(A):
• In the Assessment (A) section of the SOAP note, the therapist draws from the
subjective and objective findings and interprets the data to establish the most
appropriate therapy program.
• In this section, impairments and functional deficits are analyzed and prioritized
to determine what impact they have on the client’s occupational performance.
• Only information that was included in the Subjective or Objective section is
discussed in the Assessment section.
• The Assessment section should end with a statement justifying the need for
continued therapy services Eg: Client would benefit from activities that encourage
trunk rotation and forward lean to facilitate transfers and lower body dressing.
July 26, 2018
24

Plan(P):
• The intervention plan is outlined in the Plan (P) section.
• As the client achieves the short-term goals, the plan is revised and new short-
term goals are established.
• Documentation reflects the client’s updated goals, as well as any modifications to
the frequency of therapy.
• Suggestions for additional interventions are also included in this section.
• This information will guide subsequent treatment sessions.
July 26, 2018
25

Narrative Notes
• Documents daily client performance.
• One way to organize the narrative note is to categorize the information into the
following subsections: problem, program, results/progress, and plan.
• The problem being addressed in the treatment intervention should be clearly
identified. The impairment, as well as the functional impact, is stated.
• The intervention or intervention modality is identified in the program section.
• The results, including progress, are documented in measurable, objective
terminology. Barriers to progress are included in this section.
• The plan for future intervention is outlined in the plan section. The need to modify
goals and the rationale for this would be included here.
• In some practice settings, the narrative note is written directly in the medical chart.
July 26, 2018
26

Descriptive Notes:
• Descriptive note is useful to relay important information about the client.
• Although it is preferable to keep notes as objective as possible, it is sometimes
appropriate to include subjective information.
• Judgmental comments, negative statements, comments about other staff
members, and information not directly related to the client’s intervention
program do not belong in the official medical record.
• Unobserved behaviors that are included in the client record should be recorded
as such and a clear explanation provided as to who provided the information to
the therapist.
July 26, 2018
27

Progress Checklists or Flow Sheets:
• Checklists or flow sheets can be used to document daily performance in a
concise, efficient manner.
• Flow sheets typically use a table or graph format to record measurements at
regular intervals, usually after each session.
• Advantages of using a flow sheet or a checklist to document daily performance
on specific tasks include improved clarity and organization of data.
• They provide ease in clearly identifying the client’s functional status and
progress.
• A disadvantage of using this format for documentation is that often space is not
sufficient for the therapist.
July 26, 2018
28

RUMBA:
• According to Perinchief, is beneficial in organizing the therapist’s thought processes for effective
documentation.
• RHUMBA are acronyms:
• Is the information Relevant (the outcome must be relevant)? The goal/outcome must relate to something.
• How long will it take? Indicate when the goal/outcome will be met.
• Is the information Understandable? Anyone reading it must know what it means.
• Is the information Measurable? There must be a way to know when the goal has been met.
• Is the information Behavioral (describes behaviors)? The goal/outcome must be something that is seen or
heard.
• Is the outcome Achievable (realistic)? The goal/outcome must be do-able and realistic.
July 26, 2018
29

SMART:
• Another system that may assist the therapist in writing goals is SMART goals.
• SMART goals are also acronyms:
• Achieving this goal will make a Significant difference in the client’s life.
• You have a clear, Measurable target to aim for, and you will know when the client
has reached the goal.
• It is reasonable that the client could Achieve this goal in the time allotted.
• Long- and short-term goals Relate to each other, and the goal has a clear
connection to the client’s occupational needs.
• The goal is Time-limited: Short- and long-term goals have a designated
chronological end point.
July 26, 2018
30

Discharge Reports:
• Discharge reports are written at the conclusion of the therapy program.
• A comparison statement of functional performance from initial evaluation to
discharge is documented to demonstrate progress.
• Discharge recommendations (e.g., home programs, therapy follow-up, referral to
other programs) are made to facilitate a smooth transition from therapy.
• Clients are discharged from therapy when they have achieved established goals,
have received maximal benefit from occupational therapy services, have refused
to participate in further therapy, or have exceeded reimbursement allowances.
• The discharge summary should clearly demonstrate the efficacy of occupational
therapy services and is often used to obtain information for outcome studies.
July 26, 2018
31

Types of Documentation Reporting Formats:
• Documentation can be paper based (written record) or computer generated.
• The written medical record is still the most widely used method for recording
information.
• However, the electronic medical record (EMR) is becoming more common,
especially in large hospital settings.
• One of the problems or inconveniences that may occur with computerized
documentation involves the accessibility of computers.
• It can enhance therapist productivity by reducing the amount of time spent
writing and can guide the new therapist in choosing appropriate responses and
terminology to document what occurred with the client.
July 26, 2018
32

Confidentiality and Documentation:
• Maintaining confidentiality in documentation is the responsibility of the
occupational therapist.
• Principle 3E of the AOTA Code of Ethics addresses the issue of privacy and
confidentiality in all forms of communication, including documentation.
• “Occupational therapy personnel shall protect all privileged confidential forms of
written, verbal, and electronic communication gained from educational, practice,
research, and investigational activities unless otherwise mandated by local, state,
or federal regulations.”
July 26, 2018
33

Contd.
• Guidelines to the Code of Ethics 2 speaks directly to confidentiality issues:
• 5.1: All occupational therapy personnel shall respect the confidential nature of
information gained in any occupational therapy interaction.
• 5.2: Occupational therapy personnel shall respect the individual’s right to
privacy.
• 5.3: Occupational therapy personnel shall take all due precautions to maintain
the confidentiality of all verbal, written, and electronic, augmentative, and
nonverbal communications.
July 26, 2018
34

Legal liability:
• The medical record is a legal document to promote reimbursement and regulate
malpractices.
• All written and computerized therapy documentation must be able to endure a
legal review.
• The therapist must know what information is necessary to include in the client
record to reduce the risk of malpractice in a legal proceeding.
• All information must be accurate and based on first-hand knowledge of care.
• Deductions and assumptions are to be avoided.
• Judgmental statements do not belong in the therapy notes. The therapist instead
should describe the action, behavior, or signs and symptoms that are observed.
July 26, 2018
35

Terminology:
July 26, 2018
36

Abbreviations of clinical documentation:
A: assessment
B/S bedside
c/o complains of
FWB full weight bearing
fx fracture
po by mouth
PMH past medical history
qd every day
Sx symptoms
ther ex therapeutic exercise
tid three times daily
v.o. verbal orders
WNL within normal limits
July 26, 2018From Kettenbach G: Writing SOAP notes, ed 3, Philadelphia, Pa, 2004, FA Davis. 37

Practice-based evidence: Evaluating
the quality of occupational therapy
patient records as evidence for
practice
Helen BuchananI; Jennifer JelsmaII; Nandi SiegfriedIII
South African Journal of Occupational Therapy
April 2016
July 26, 2018 38

Research details:
• Aim: Occupational therapy patient records are required for legal purposes, but
may also be used to produce evidence for practice. The aim was to establish how
comprehensively occupational therapists documented patient records.
• METHODOLOGY: they conducted a descriptive cross-sectional study of
occupational therapists at public health facilities in a South African province.
Trained raters audited five randomly-drawn records per participant using a
checklist developed for the study. The maximum possible score was nine and the
lowest was zero. Audits were checked for consistency.
July 26, 2018 39

Results/conclusion:
• RESULTS: Forty-nine occupational therapists participated and 240 records were
audited. Records contained information on intervention (96%) and changes
occurring at impairment (82%) and activity and participation levels (64%).
Documentation of baseline assessment (impairment level: 20%; activity and
participation level: 10.4%) and re-assessment (impairment level: 7%; activity and
participation level: 0.0%) was limited. Audit scores were significantly better in
the work practice area (H=16.10, p=0.003) and among therapists in urban areas
(U=24.50, p<0.001).There was a significant negative correlation between audit
score and number of clients seen per month (rs=-0.46, p<0.001).
• CONCLUSION: The low audit scores suggest that the records did not contain
sufficient information to produce robust evidence. Manageable ways of
documenting occupational therapy practice need to be devised.
July 26, 2018 40

Objectives:
• What are the purposes of documentation?
• The important elements of documentation?
• What are the types of occupational therapy documentation?
• What are SOAP Notes, RUMBA and SMART refers to?
• What are the types of Documentation Reporting Formats?
• Why is confidentiality important in documentation and what is its governing
body?
• What is the legal importance of documentation?
July 26, 2018 41

References:
• Pendleton HM, Schultz-Krohn W. Pedretti's Occupational Therapy-E-Book:
Practice Skills for Physical Dysfunction. Elsevier Health Sciences; 2017 Mar 10.
• Date from American Occupational Therapy Association (AOTA): Guidelines to
the occupational therapy code of ethics, Am J Occup Ther 60:652-658, 2006.
• https://www.aota.org/Practice/Manage/Reimb/documentation-dos-donts-tips-
from-OT-managers.aspx
• From Kettenbach G: Writing SOAP notes, ed 3, Philadelphia, Pa, 2004, FA Davis.
July 26, 2018 42

Doubts/questions/add-ons
July 26, 2018 43

Aota occupational profile template
July 26, 2018 45

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