Get Casamba Documentation Sample Occupational Therapy

Though occupational therapy documentation is a practical necessity, providing good documentation on every patient also helps to demonstrate your value as a quality provider. ... It gives you the ability to communicate with other healthcare providers, to defend treatment choices, and to track progress.

Get the basics. Many physical therapy facilities provide staff with fill-in-the-blank type forms that outline exactly what the OTs need to keep track of. ... Be specific. OTs must be thorough when taking their notes. ... Think about the client. ... Write clearly.

Casamba Skilled streamlines everything from operational, clinical and financial workflows for providers in Skilled Nursing Facilities (SNFs), including documentation, reporting and analytics, case management, scheduling, and much more.

11507-1Occupational therapy Progress noteActive Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."

How does all of this information fit together? Where (in your professional opinion) should the patient go from here? Where does OT fit into the picture for the patient's plan?

Progress notes are considered part of the client's record or file. Progress notes usually follow a standardized format, such as SOAP (Subjective, Objective, Assessment, and Plan) and include details of your client's symptoms, assessment, diagnosis, and treatment.

Use a consistent structure and flow. Create a unique note for every appointment. Establish a reasonable number of goals. Complete notes in a timely manner. Make sure your notes are legible. Include all the details of the session. Don't include unnecessary information.

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Four types of writing will be addressed: journal or reflective writing, developing fact sheets or handouts, technical writing specific to the profession, and scholarly writing of research papers (i.e., professional summaries, research papers, etc.).