A Simple Introduction to Documentation

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

I wanted to provide examples of OT documentation that may be useful to new graduate OTs, students, 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.

Assessment Section Example: Acute Care

(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).

Documentation: Evaluation in Outpatient OT

Examples of documenting OT standardized assessments in the adult outpatient setting.

  • Therapist administered hand-held dynamometer (R dominant hand average: 40 kg; L hand average: 6.5). Pt consistently demonstrates L-sided weakness secondary to previous CVA. 

  • Therapist administered the Nine Hole Peg Test (R dominant hand average: 35 seconds; L hand average: 55 seconds).

  • Therapist administered the MMSE to assess baseline cognition. Pt scored a 23/30 demonstrating mild cognitive impairment and increased odds of dementia. 

  • Patient completed the Clock Drawing Test as part of a cognitive-perceptual screening. The clock was drawn accurately with all numbers placed in correct sequence and spatial orientation, and clock hands correctly positioned to reflect the given time, however the clock was small in size, which may suggest fine motor or visual-spatial deficits. Will continue to assess visual/ depth perception. 

  • Therapist administered the Berg Balance Scale to assess baseline sitting and standing balance. Pt scored a ___ demonstrating ___.

Documentation: Treatment

Examples of documenting OT treatments in the adult outpatient setting.

  • Therapist intro'd and educated pt and pt's wife on UE HEP to be completed 10 sets each/ 3 rounds, 2-3x per day with good understanding verbalized and demonstrated. 

  • Pt engaged in seated functional reach activity using yellow, green, blue, and red pegs. Therapist instructed patient to grasp a specific color peg (yellow, green, blue, or red) with L hand, and place on towel draped over easel 5 feet in front of patient. Pt able to place 12 pegs on easel with no overt symptoms of fatigue or pain.

    Pt engaged in seated fine motor activity using 4 cones (red, blue, yellow, and orange), and instructed to pick up marbles one at a time and place into specific cone to facilitate in hand manipulation skills/ fine motor skills. 

    Seated at the table, pt engaged in fine motor/coordination activity using clothespins to facilitate functional reach and dynamic balance for dressing tasks. Clothespins were placed on the left hem and sleeve of patients shirt and pants. Patient demonstrated reaching across midline and downward to remove clothespins using the right hand with 1/2 lb weight. Patient completed activity on the opposite side, reaching with left hand with 1/2 lb weight, with goal of increasing fine motor and coordination. Patient tolerated activity well and reported no pain or fatigue. 

    Patient engaged in reaching tasks using color coded clothespins in multiple directions while seated unsupported on therapy mat. Patient tolerated session well with minimal fatigue. Demonstrated improved postural control during seated balance activity compared to previous session. 

  • Golf simulation: Engaged patient in a occupation-based dynamic standing/seated balance activity (golf simulation) to address seated balance, standing balance, motor planning, coordination, and strength/ endurance. Activity was modified to sitting in wheelchair, to accommodate endurance limitations. 

  • Therapist initiated bed mobility training on this date, based on the patient's previously stated goals. Practiced supine to sit and sit to supine transitions on therapy mat with verbal cues and minimal assistance with focus on core and trunk control. 

  • Patient engaged in a dynamic standing/sitting balance activity at the mat, utilizing medication pill organizer to target visual perception, visual scanning, and problem-solving. The task involved sorting medications (dried beans) into pill organizer by time of day and pill number. Patient was able to complete 4 out of 8 levels while standing, ~5 minutes before requiring a seated rest break due to verbalized fatigue. Patient completed the last 4 levels sitting. Patient demonstrated good effort and concentration; however, moderate challenges were noted in depth perception and visual organization due to diplopia and memory. Continuous verbal cues were provided for reaching with affected left hand and stabilizing with right hand, as well as cues regarding pill placement. Patient tolerated activity well and would benefit from continued visual perceptual/ executive functioning training to progress toward goals. 

  • Patient participated in a dynamic standing balance activity involving locating and retrieving numbered cards (1-15) placed throughout the therapy room. Activity required the patient to visually scan environment, maintain upright posture, and ambulate short distances between targets. Patient demonstrated ability to reach outside base of support, shift weight, and perform visual tracking tasks while maintaining standing balance using RW and supervision-CGA.   

  • Patient participated in a dynamic standing balance activity at mat level involving locating and grasping towels placed in various planes throughout therapy room using long handled Reacher. Activity required patient to visually scan environment, maintain upright posture, and reach outside of base of support. Patient able to retrieved 10/10 towels and instructed to fold/ roll towels based on verbal instruction. Patient tolerated activity well, with no verbalized fatigue or pain.  

  • Patient participated in a dual-task activity involving reciprocal bouncing of a therapy ball with the therapist while simultaneously verbalizing one item per turn from a given category (e.g., animals, sports, and foods). Task targeted depth perception, visual scanning, and memory.