Documentation & Reimbursement

Need help with documentation? AOTA helps members by providing best practices for documentation to help you increase reimbursement, decrease denied claims, and articulate the distinct value of occupational therapy.

General Documentation Tips for All Practitioners

Improve Your Documentation With AOTA's Occupational Profile Template
Every OT evaluation should include an occupational profile. Download and print this template to assist you in documenting your clients' occupational profiles.

Use "AOTA PERFORM" to Add OT-Specific Fields to Your Electronic Health Record System Member only content 
The PERFORM document is a deconstruction of the 3-part evaluation section of the Process section of the Occupational Therapy Practice Framework: Domain and Process, 3rd edition (OTPF), and provide a detailed overview of the components that should be included in an occupational therapy evaluation.

Download Template to Document How OT Helps Clients Achieve Outcomes
If you work in a SNF, IRF, long-term-care hospital, or home health, you can help increase recognition of OT’s effectiveness in your facility. Watch a quick video and download our free tool to get started.

Tips for Maximizing Your Clinical Documentation Member only content
Get examples and tips on documenting evaluations/plan of care, interventions, progress notes, and discharge summaries.

Do’s and Don’ts of Documentation: Tips From OT Managers Member only content
A collection of the best advice for documentation from participants of AOTA’s Leadership Development Program for Managers. Hone your documentation skills and improve your efficiency.

How To Be More Effective With Documentation: Q&A With Cathy Brennan
What’s the most common documentation mistake? How do you deal with point-of-service documentation? This Q&A has the answers.

Point-of-Service Documentation Strategies Help Practitioners Beat the Time Crunch pdf Member only content
Read this OT Practice article for tips for completing on-the-spot documentation, whether using electronic devices or paper forms.

Your Questions Answered: Documentation pdf Member only content
Answers to questions from the field, including how to ensure documentation meets the diverse expectations from a facility, third-party payers and others who read it in the Administration & Management SIS Quarterly, December 2010.

FAQ on Ethics in Skilled Nursing Facilities: Productivity, Supervision, & Medicare Guidelines Member only content
Get answers to questions about productivity and ethics issues that many of our members who work in SNFs struggle with.

Children & Youth: Tips for Early Intervention and School-Based

Documenting and Organizing Quantitative Data in School Practice Documentation Member only content
This OT Practice article describes a method for collecting and organizing quantitative information to help improve your school practice documentation.

School-Based Practice Documentation Tips: Save Time & Highlight OT's Distinct Value Member only content
We know the life of a school-based OT practitioner can be very busy and hectic. Get documentation tips to save time while highlighting the OT distinct value.

Writing Pediatric Goals: How to Document Family Involvement & Developmental Progress Member only content
These tips for writing pediatric goals include examples of how to include family involvement and developmental progress in your goals and how to show progress from OT services when IFSP outcomes overlap with other disciplines.

How to Fix Common Early Intervention Documentation Mistakes Member only content
If you work in early intervention, you might be making some of these common mistakes in your documentation. Find out how to avoid mistakes and be more efficient with these tips from Ashley Stoffel, OTD, OTR/L.

More Information:

Official Document: Guidelines for Documentation of Occupational Therapy Member only content
The official document, based on the Framework, describes the components and purpose of professional documentation used in occupational therapy.

AOTA advocates for fair coverage and payment policies for occupational therapy practitioners by public and private health insurers and organizations that provide referrals to—and payment for—occupational therapy services. Find out about our current advocacy work here, including resources for coding and how to adhere to regulations. Get additional reimbursement resources.