Individuals working in occupational therapy jobs have a lot of day-to-day duties. Their responsibilities involve evaluating patients, setting goals, implementing an intervention plan to help people reach those goals, assessing the outcomes of the strategies used and deciding where there’s room for improvement. While this process calls on the OT’s strength, compassion and patience, it also requires the healthcare professional to be an excellent writer and communicator.
OTs must record just about every step of the process, from the initial consultation to the conclusion of a treatment plan. However, the progress notes taken during the intervention phase hold unique importance, as they help demonstrate the necessity of an OT’s service. As The American Occupational Therapy Association explained, the Affordable Care Act-prompted switch from fee-for-service to value-based reimbursement has added a new challenge to data collection. While OTs have always prioritized quality over quantity by the very nature of their jobs, the new payment method forces OTs to argue the worth of their services, which requires effective and thorough progress notes. Here’s how OTs can make the most of each entry:
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. However, OTs may benefit from developing their own understanding of what’s necessary to create sufficient records, as these documents leave wiggle room for both improvement or error. Plus, by getting the basics, OTs can easily transition if they switch to a job that has different forms than their previous facility.
According to a study published in 2013 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, progress notes should include four categories:
- Client information.
- Summary of services the OT provided.
- Current client progress update.
- Plans and recommendations.
OTs must be thorough when taking their notes. For instance, OTs should record more than just the patient’s name and birth date for client information. This section should also include diagnosis, gender and precautions.
Similarly, for summary of services provided, the OT must note the strategies used, when and how they were completed, what outcomes were measured, consultation and education given, and programs utilized, along with any other pertinent information. This section highlights the value of OT services. As the study listed above noted, healthcare professionals should use more than just the client’s diagnosis to rationalize the intervention.
Think about the client
OTs likely think about nothing else but their clients, and it’s important to put what’s on their mind on paper. That is, OTs must differentiate their notes based on clients’ needs and preferences – no two patient records should look the same. Emillee Johnson, director of rehabilitation services at Maria Parham Medical Center, explained to the AOTA that taking this step puts more power behind the rationale for the intervention plan.
Legibility plays a huge role in ensuring the notes demonstrate the value of the OT’s services. It can be all too easy for busy healthcare professionals to scribble a few notes between appointments, using their knees as desks and broken pencils to write. For OTs who don’t record notes electronically, they should take time to write clearly so all healthcare professionals can understand the client’s progress. To save time and avoid rushing through writing, OTs may benefit from keeping a pen on them at all times.
Finally, OTs should follow the motto “when in doubt, write it down.” Between all the different clients who walk into the medical facility, it can be difficult for healthcare professionals to keep track of individual patients’ performance. Recording specific details in a timely manner can make progress notes more effective.