Documenting functional cognition

Occupational therapy’s role in addressing cognitive deficits can be difficult to define, often sounding too similar to services offered by speech-language pathologists or physical therapists, creating confusion or the appearance of duplication. Although many occupational therapy practitioners (OTPs) address cognition during functional tasks and in occupation-based sessions, the assessments and generic documentation terms OTPs use often mimic those used by other disciplines, which fails to articulate how the client’s functional cognition is affecting performance. Improving documentation to highlight occupational therapy’s unique contributions in assessing and treating clients with impairments in cognitive function is one way to help differentiate our role. This article describes how one hospital changed the occupational therapy documentation in acute care to better represent occupational therapy’s role in functional cognition.