OT practitioners spend lots of time on documentation.
Our notes help us track patients’ progress, communicate with other healthcare providers, and defend our rationale for our treatment choices. Documentation is a key factor in our patients’ well-being during their continuum of care.
But, as we all know, charting can take FOREVER—and we might not have the time we need to do it justice.
We are constantly grappling between wanting to write the perfect OT note—one that succinctly says what we did and why we did it—and finishing as quickly as possible.
My vision (and I’ll admit it’s a grand one) is to help you create the type of notes that clearly communicate your assessments and plans, without making you lose your mind in the process.
We’ll start with some basic do’s and don’ts of effective documentation. Then, at the end of the article, you’ll find a sample OT evaluation and some more resources to help you improve your note-writing game.
Do’s and Don’ts of writing occupational therapy documentation:
(We’ll take one SOAP note section at a time)
DO use the subjective part of the note to open your story
Each note should tell a story about your patient, and your subjective portion should set the stage.
Try to open your note with feedback from the patient about what is and isn’t working about their therapy sessions and home exercise program. For example, you can say any of the following to get your note started:
- “Patient states she was excited about ____.”
- “Patient reports he is frustrated he still can’t do ____.”
- “Patient had a setback this past weekend because ____.”
By sentence one, you’ve already begun to justify why you’re there!
DON’T go overboard with unnecessary details
Let’s admit it: we are storytellers, and we like to add details. But, we must admit we’ve all seen notes with way too much unnecessary information. Here are a few things you can generally leave out of your notes:
- “Patient was seated in chair on arrival.”
- “Patient let me into her home.”
- “Patient requested that nursing clean his room.”
Details are great, because they help preserve the humanity of our patients, but it’s really not necessary to waste your precious time typing out details like these.
Keep in mind that the exception to the above rule is that if a patient is mistrustful of you in any way, adding key details about being let into his or her home might be very relevant!
Channel your inner English major. If a detail does not contribute to the story you are telling—or, in OT terms, contribute to improving a patient’s function—you probably don’t need to include it 🙂
DO go into detail about your observations and interventions
The objective section of your evaluation and/or SOAP note is often the longest. This is almost certainly the case in an evaluation.
This section should contain objective measurements, observations, and test results. Here are a few examples of what you should include:
- Manual muscle tests (MMTs)
- Range of motion measurements (AAROM, AROM, PROM, etc.)
- Level of independence (CGA, MIN A, etc.)
- Functional reporting measures (DASH screen, etc.)
- Wound healing details (for post-op patients)
- Objective measures from assessments related to the diagnosis
For a comprehensive list of objective measurements that you can include in this section, check out our blog post on OT assessments. We compiled over 100 assessments you can choose from to gather the most helpful data possible.
DO show clinical reasoning and expertise
The assessment section of your OT note is what justifies your involvement in this patient’s care.
What you’re doing in this section is synthesizing how the story the patient tells combines with the objective measurements you took (and overall observations you made) during today’s treatment session.
The assessment answers the questions:
- 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?
DON’T skimp on the assessment section
The assessment section is your place to shine! All of your education and experience should really drive this one paragraph.
We tend to just write: “Patient tolerated therapy well.” Or we copy and paste a generic sentence like this: “Patient continues to require verbal cueing and will benefit from continued therapy.”
Lack of pizazz aside, that’s not enough to represent all that education you have, nor all that high-level thinking you do during your treatments.
Consider something like:
“Patient’s reported improvements in tolerance to toileting activities demonstrate effectiveness of energy conservation techniques she has learned during OT sessions. Improved range of motion and stability of her right arm confirms that her use of shoulder home exercise plan is improving her ability to use her right upper extremity to gain independence with self care.”
DON’T get lazy
I once went to a CEU course on note-writing, and the course was geared toward PTs.
It felt to me like most of the hour was spent talking about how important it is to make goals functional. But we OTs already know this; function is our bread and butter.
So, why do many OTs insist on writing things like: “Continue plan of care as tolerated”??
Not only do utilization reviewers hate that type of generic language, it robs us of the ability to demonstrate our clinical reasoning and treatment rationale!
DO show proper strategic planning of patients’ care
This section isn’t rocket science. You don’t have to write a novel. But you do need to show that you’re thinking ahead and considering how your patients’ care plans will change as they progress through treatment.
Consider something like this:
“Continue working with patient on toileting, while gradually decreasing verbal and tactile cues, which will enable patient to become more confident and independent. Add stability exercises to home exercise program to stabilize patient’s right upper extremity in the new range. Decrease OT frequency from 3x/week to 2x/week as tolerated.”
Short, sweet, and meaningful.
General DO’s and DON’TS for documentation
Your patient is the hero—and you are the guide. In every good story, there’s a hero and a guide. The patient is Luke Skywalker, and you are Yoda.
I think as therapists, we tend to document only one part of the story.
For example, we focus on the hero’s role: “Patient did such and such.”
Or we focus on what we, the guide, bring with our skilled interventions: “Therapist downgraded, corrected, provided verbal cues.”
But, a really good note—dare I say, a perfect note—shows how the two interact.
If your patient tells you in the subjective section that they are not progressing as quickly as they would like, what did you do, as the therapist, to upgrade their intervention? Your notes should make it apparent that you are working together as a team.
Let’s look at a few examples:
- “Patient reported illness over the weekend; thus activities and exercises were downgraded today. Plan to increase intensity when patient feels fully recovered.”
- “Patient has been making good progress towards goals, and is eager for more home exercises. Plan to add additional stability work at next visit.”
DO be very careful with abbreviations
While I was creating this blog post, I read every piece of advice I could find on documentation—and I had to chuckle because there was simply no consensus on abbreviations.
Abbreviations are obviously great because they save time—but they can make our notes cryptic (useless) to others.
In the ideal world, we type the abbreviation and our smartie computer fills in the full word or phrase for us. And, for those of us who use an EMR on Google Chrome, this is exactly what can happen. I also know that WebPT allows this integration.
If you don’t already use keyboard shortcuts, contact your IT department and see if there are any options within your EMR. If there aren’t ways to implement these shortcuts, I highly recommend that you request them!
I’ve got an article about OT documentation hacks that delves more into the topics of text expanders and abbreviations!
After all of this, I bet you’re ready to see an OT evaluation in action. You’re in luck because I have an example for you below!
Example Outpatient Occupational Therapy Evaluation
Name: Phillip Peppercorn
Evaluation date: 12/10/18
Diagnoses: G56.01, M19.041
Treatment diagnoses: M62.81, R27, M79.641
Referring physician: Dr. Balsamic
Visits used this year: 0
Patient is a right-handed male software engineer who states he had a severe increase in pain and tingling in his right hand, which led to right carpal tunnel release surgery 11/30/18. He presents to OT with complaints of pain and residual stiffness while performing typing movements, stating “I’m supposed to go back to work in three weeks, and I don’t know how I will be able to function with this pain.”
Post surgery, patient complains of 2/10 pain at rest and 7/10 shooting pain at palmar region extending to second and third digits of right hand when working at his computer for extended periods of time, as well as doing basic household chores that involve carrying heavy objects, like laundry and groceries. The numbness and tingling he was feeling prior to surgery has resolved dramatically.
Past medical/surgical history: anemia, diabetes, right open carpal tunnel release surgery on 11/30/18
Hand dominance: right dominant
IADLs: independent, reports difficulty typing on phone and laptop, and with opening and closing his laptop computer since surgery
ADLs: opening drawers at work, opening door handles at office building
Living environment: lives alone in single-level apartment
Prior level of functioning: independent in work duties, activities of daily living, and instrumental activities of daily living.
Occupational function: works a job as a software engineer; begins light-duty work with no typing on 12/20, MD cleared for 4 initial weeks
Range of motion and strength:
Left upper extremity: Range of motion within functional limits at all joints and on all planes.
Right upper extremity: Right shoulder, elbow, forearm, digit range of motion all within normal limits on all planes.
Flexion/extension—Strength: 4/5, AROM: 50/50, PROM: 60/60
Radial/ulnar deviation—Strength: 4/5, AROM: WNL, PROM: NT
Left hand: 65/60/70
Right hand: 45/40/40
Boston Carpal Tunnel Outcomes Questionnaire (BCTOQ)
Symptom Score = 2.7
Functional Score = 2.4
Sutures were removed, and wound is healing well with some edema, surgical glue, and scabbing remaining.
Patient was provided education regarding ergonomic setup at work and home, along with home exercise program, including active digital flexor tendon gliding, wrist flexion and extension active range of motion, active thumb opposition, active isolated flexor pollicis longus glide, and passive wrist extension for completion 4-6x/day each day at 5-10 repetitions.
He was able to verbally repeat the home exercise program and demonstrate for therapist, and was given handout.
Patient was given verbal and written instruction in scar management techniques and scar mobilization massage (3x/day for 3-5 minutes). He was also issued a scar pad to be worn overnight, along with a tubular compression sleeve.
Mr. Peppercorn is a 46-year-old male, who presents with decreased right grip strength and range of motion, as well as persistent pain, following carpal tunnel release surgery. These deficits have a negative impact on his ability to write, type, and open his laptop and door handles. Anticipate patient may progress more slowly due to diabetes in initial weeks, but BCTOQ reflects that patient is not progressing as quickly as normal, and is at risk of falling into projected 10-30% of patients that do not have positive outcomes following carpal tunnel release. Patient will benefit from skilled OT in order to address these deficits, adhere to post-op treatment protocol, and return to work on light duty for initial four weeks.
Plan of care
Recommend skilled OT services 1x/week consisting of therapeutic exercises, therapeutic activities, ultrasound, phonophoresis, e-stim, hot/cold therapy, and manual techniques. Services will address deficits in the areas of grip strength and range of motion, as well as right hand pain. Plan of care will address patient’s difficulty with writing, typing, and opening and closing his laptop and door handles.
Short Term Goals (2 weeks)
- Patient will increase dynamometer score in bilateral hands to 75 lb in order to do laundry.
- Patient will increase right digit strength to 3+/5 in order to open door handles without using left hand for support.
Long Term Goals (6 weeks)
- Patient will increase right wrist strength to 5/5 to carry groceries into his apartment.
- Patent will increase active range of motion in wrist to within normal limits in order to open and close his laptop and use door handles without increased pain.
- Patient will increase dynamometer score in bilateral hands to 90 lb in order to return to recreational activities.
- Patient’s Boston Carpal Tunnel Outcomes Questionnaire score will decrease to less than 1.7 on symptoms and function to return to work and social activities without restrictions.
O. Therapist, OTR/L
97165 – occupational therapy evaluation – 1 unit
97530 – therapeutic activities – 1 unit (15 min)
97110 – therapeutic exercises – 2 unit (30 min)
Well! This was certainly involved, but the experts tell me that the above evaluation represents what needs to be documented to satisfy insurance companies. I spelled out lots of areas where you might normally use abbreviations, but I wanted other medical professionals and patients to have a clear understanding of what our treatments are, and why we use them.
Keep in mind that there’s really no such thing as a “perfect” OT note, despite what I’m saying in this article. Every patient presentation will warrant its own treatment approach, and the best thing we can do is document our clinical reasoning to support our interventions.
More resources for improving your documentation
I recognize that defensible documentation is an ever-evolving art and science, and have come across many useful resources that will help you keep your notes complete, yet concise. I highly recommend the following:
- The Seniors Flourish Podcast: Simplify Your Documentation (five-part series)
- WebPT: Defensible Documentation Toolkit (download required)
- The Note Ninjas: See their website
- A Witty PT: Medical Necessity in Rehab
In the OT Potential Club, which is our OT evidence-based practice club, you can also access our library of documentation examples (we add one each month). They are intended to be discussion-starters to help us improve our documentation skills.
Here’s the examples we have so far:
Acute Care—Adults & Pediatric
- Acute Care OT Eval (s/p THA)
- Acute Care OT Tx Note (s/p THA)
- Acute Pediatric OT Eval (diagnosis: acute myeloid leukemia)
- Acute Pediatric Tx Note (diagnosis: acute myeloid leukemia)
- Inpatient Rehabilitation Eval (diagnosis: ischemic stroke)
Assisted Living Facilities (ALF)
- ALF OT Eval (s/p fall)
- ALF Treatment Note (s/p fall)
Early Intervention (EI)
- EI Eval (diagnosis: Down’s Syndrome)
- EI Tx Note (diagnosis: Down’s Syndrome)
- Telehealth EI Development Eval
- Home Health OT Eval (s/p femur fx)
Outpatient (OP)—Adults & Pediatric
- Home-visit Treatment Note (Showcasing caregiver support)
- OP Eval (diagnosis: POTS)
- OP OT Eval (diagnosis: carpal tunnel release)
- OP OT Evaluation (s/p concussion)
- OP Pediatric Eval (diagnosis: autism, ADHD)
- OP Pediatric OT Eval (diagnosis: autism)
- OP Tx Note (diagnosis: Multiple Sclerosis, participatory medicine tx approach)
- OT Treatment Note (s/p concussion)
- OP Tx Note (diagnosis: post-stroke, self-management tx approach)
- Power Wheelchair Evaluation
- Power Wheelchair Treatment Note
- Pediatric Telehealth Eval—Private Pay
- Pediatric Telehealth Tx Note—Private Pay
- OT Inpatient Psych Eval (adolescent with suicidal ideation)
- OT Inpatient Psych Treatment Notes (adolescent with suicidal ideation)
- School-based OT Eval Report: (diagnosis: autism)
- School OT Eval (diagnosis: Down’s Syndrome)
- Telehealth School OT Eval Example (diagnosis: trisomy 21)
- Telehealth School OT Tx Note (diagnosis: trisomy 21)
Skilled Nursing Facility (SNF)
- SNF OT Eval (s/p THA)
- SNF OT Tx Note (s/p THA)
Documentation can get a bad rap, but I believe that OT practitioners are uniquely poised to write notes that are meaningful to other healthcare practitioners and patients alike.
It seems inevitable that our patients will gain easier access to their notes over the next decade, and when they do, I want our documentation to stand out as relevant and useful.
This article is meant to evolve over time, so I’d love to know the types of notes you’d like me to provide in the article. Is there any way you would improve upon the example I’ve provided? Please let me know in the comments!
A special thanks to:
The Note Ninjas
The Note Ninjas was founded by Nicole Trubin, MS, OTR/L and Stephanie Mayer, PT, DPT. They created their Instagram account and website to serve as resources for other clinicians and students. Their focus is to provide skilled treatment ideas and show how to support chosen interventions in your documentation. Documentation plays a vital role in patient care and can be complex. Their mission is to teach others how to continue to show skilled services and how to progress skilled intervention to avoid discharging a patient too early.
See how the OT Potential Club can elevate your OT evidence-based practice.
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