Maximizing your clinical documentation

This Practice Improvement Perk can be read in its entirety on the AOTA website: https://www.aota.org/-/media/corporate/files/practice/practice-essentials/quality/maximizing-your-clinical-documentation.pdf.

Evaluation/Plan of Care

• Link objective information and test scores to functional performance and participation.
• Add pertinent medical and/or family history that could have an impact on the plan of care.
• Address cognitive level if it has an effect on the intervention.
• Identify why the specific skills of an occupational therapy practitioner is required.
• Include an adequate baselines of functional deficits and underlying impairments to measure change and support treatment interventions.
• Clearly state the frequency and duration of necessary therapy treatment.
• Goals must be client-centered and measurable.

Intervention

• Document current client status by identifying the specific outcome/goal being addressed and how the client is responding at present.
• Use action verbs such as evaluate, fabricate, analyze, tailor, grade, develop, design, optimize, stabilize, facilitate, inhibit, and educate to describe skilled service in notes.
• Be sure the coding, intervention descriptions, and dates within the intervention notes are accurate and consistent.
• Indicate whether group or concurrent therapy is being furnished.

Progress Notes

• Indicate why the frequency or duration of treatment has changed.
• Use approved abbreviations, and spell out the full abbreviation at the outset in your documentation.
• Indicate how your interventions achieve functional performance, participation, or other outcome, rather than just describing the activities themselves.
• Address each original goal in the progress report.
• Address any lack of progress with explanation of why progress was not achieved and how the treatment plan will be adapted to address the lack of progress.
• Summarize skilled services provided during the intervention period to further justify why the specific skill set of an occupational therapy practitioner was required.
• Explain why continued services are needed to reach the goals in the plan of care.
• Document when OTA notes have been reviewed by an OT. OTA supervision should be documented in accordance with each state’s practice act.

Discharge Summary

• Identify appropriate carryover training for the caregiver.
• Summarize the client’s progress from the start of care to the end of the episode. Paint a picture of the client’s functional status at the start and end of care.
• Summarize skilled intervention delivered over the course of the episode.

Adapted from “The Do’s and Don’ts of Documentation: Pitfalls to Avoid,” by C. Brennan, 2015, OT Practice, 20(14), pp. 8–11. Disclaimer: This information is for general guidance only. Practitioners should consult with their payer source for specific documentation requirements and refer to their state practice act when documenting OTA supervision. For more information, visit https://www.aota.org/practice/practice-essentials/payment-policy.

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