A Simple Introduction to Documentation

Every patient is unique and requires individualized, occupation-based documentation and goals.

I wanted to provide examples of documentation and goals that may be useful to a new-grad OT, student, or anyone looking for ideas to grow as a clinician!

  • In the hospital setting, once the Occupational Therapist (OT) receives an OT referral from the physician, an evaluation can be administered.

  • After a chart review, and a face-to-face evaluation with the patient (and potentially the patient’s family), the occupational therapist determines if the patient may benefit from additional OT services while admitted to the hospital, home health, post acute, and/or outpatient.

  • There are several factors to effective documentation including the assessment, recommendations (further skilled home health (HH) OT or outpatient (OP) OT, DME, and/or adaptive equipment (AE)), and developing client-centered goals.

How to document the Assessment Section

After completing the evaluation, it is essential to document exactly what you observed and accomplished during the allotted time you were in the patient’s room.

What is in the assessment section of an evaluation note? An assessment section typically contains patient identifiers, diagnosis, past medical history, presentation, assist level, AE/DME needs, and recommendations.

  • Mr/Ms. _____ is a ___ y/o M/F admitted s/p (status post) _____.

    Example: Patient is a 86 y/o male admitted s/p stroke-like symptoms presenting with facial droop.

    • Bed orders

    • Weight-bearing status

    • Imaging

    • Orientation

    • Activity tolerance

    • Generalized muscle weakness

    • Pain

    • Decreased balance

    Example: Pt is alert and oriented, able to follow simple commands, and communicates verbally. Pt presented with decreased activity tolerance, generalized muscle weakness, and pain; manifesting as performance deficits with standing ADLs and functional mobility.

  • Independent

    Modified Independent (mod I)

    Supervision

    Stand by Assist (SBA)

    Contact Guard Assist (CGA)

    Minimum Assist (min A) requires 25% therapist assist

    Moderate Assist (mod A) requires 50% therapist assist

    Maximum Assist (max A) requires 75-99% therapist assist

    Dependent Requires 100% of therapist assist

    Ex: Pt requires (assist level) for standing ADLs and (assist level) functional mobility.

  • Discharge recommendations include:

    (OT’s can make their recommendations, however it depends on the patient’s insurance/ other discipline recommendations as well.)

    • Home Independently: No need for further OT services.

      • Example: Pt does not require additional OT services and is safe to d/c home independently. Discontinue OT.

    • Home with Caregiver Assist

      • Example: Pt does not require additional skilled OT services and is safe to d/c home with caregiver assist and HH OT.

    • Post-Acute Stay: Further stay in the hospital and would benefit from continued OT services.

      • Example:

        Pt would benefit from continued skilled OT services to increase safety and functional independence. Recommend post acute stay.

    • Home Health OT

      • Example: Recommend HH OT to increase safety and functional independence.

    • Outpatient OT

      • Example: Recommend OP (outpatient) OT to increase safety and functional independence.

Assessment Section Example

(modify to your patient's specific needs)

Mr/Ms is a ___ y/o M/F referred to skilled OT services to address functional deficits related to (diagnosis). At baseline, pt is (independent) with ADLs, (mod I) with functional mobility (uses RW), and lives with (spouse). Pt with medical history of ___. Pt presented with (e.g., decreased activity tolerance, generalized muscle weakness, and pain) manifesting as performance deficits with (standing ADLs and functional mobility). Pt requires (assist level) for standing ADLs and (assist level) for functional mobility/ transfers. Recommend (home independently/ caregiver assist/ post acute stay).

Goal Writing

Here are a few examples of diagnosis-specific goals that I use for patients in acute care.

Remember, every patient is unique and require development of individualized, occupation-based goals.

  • Example for use of resting hand splint:

    Recommended R/L resting hand splint for pt to wear at nighttime-only to assist c spasticity mgmt. Provided family c handout including appropriate sizing for purchase on Amazon. Family edu to only wear at night and regularly check pt’s skin for marks/pressure points/edema.

  • Total Hip Replacement

    Example for lower body (LB) dressing using adaptive equipment (AE):

    • Therapist intro’d and educated on AE (reacher, dressing stick, long handled shoe horn) to increase independence in LBD. Provided pt c verbal/visual demo on AE use, then had pt provide return demo c good understanding demonstrated. Pt able to use Reacher to don pants, then use LHSH to don shoes w/o assist.

    • Pt will increase activity tolerance for ADLs using energy conservation techniques by utilizing shower chair during bathing.

Goal Writing Continued

Here are a few examples of intervention-based goals that I use for patients in acute care.

  • Neuromuscular Re-Education aims to develop movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/ or standing activities.

    Example:

    Patient engaged in proprioceptive neuromuscular facilitation (PNF) of the LUE to promote decreased spasticity and increase ROM performing 2 sets of 10 reps through D1 and D2 movement patterns with good understanding demonstrated.

    • Pt will perform UE HEP 3x per day for 10 sets each to improve UE strength, improve endurance, and increase activity tolerance to participate in ADLs w/ stable vital signs.

  • Pt will complete dynamic standing balance task x5 minutes w/ spO2 reading at 90% or higher x5 minutes independent prior to D/C.

  • 5x sit to stand 

    Pt will demonstrate improved lower body strength and muscle stamina as evidenced by performing the 5 times sit to stand assessment independently or with CGA and improving by at least 6 seconds in order to improve functional transfers, bed mobility, and ascending/descending stairs necessary to be independent at home and in the community.