Documentation and Observation Basics

Question 1

The WHO of documentation

Answer 1

• You and anyone else providing care will contribute to the record.
• Audience you are writing to (make understandable to all): Intervention team, insurance, caregivers/family, accrediting agencies, supervisors, lawyers, researchers, facility quality managers, etc.
• OT documents overall evaluation; OTA may assist in eval process as delegated
• OTA usually writes treatment/visit/daily note, and possibly progress note
• OT must co-sign notes by OTAs/OTASs

Question 2

The WHAT of documentation

Answer 2

• What was done? Puts it in stone. What do you observe?
• What was client’s reaction (physically/emo)
• Demonstration of skilled services/complexity/education
• Functional, client-centered, occupation-based
• Clear, concise, activity able to be duplicated

Question 3

The WHEN of documentation

Answer 3

• As close to time of service as possible.
• Sometimes point-of-service documenting
• Often done when no clients being treated
• Make at least brief notes throughout day

Question 4

The WHERE of documentation

Answer 4

• In each clinical setting, each client has his own clinical record/chart
• May be computer, paper, or both

Question 5

The WHY of documentation

Answer 5

• To show what happened in chronological sequence
• To show high level of clinical reasoning
• To inform others on intervention team what happened
• To demonstrate effectiveness of OT for third-party payers
• For legal reasons

Question 6

Questions to ask yourself when observing a client:

Answer 6

• WHO is involved in treatment session?
• WHEN did tx session take place?
• WHERE did tx session take place?
• WHAT happened during tx session?
• WHY is the particular tx intervention important?
• HOW did the client perform/participate in the task?

Question 7

Why observation is important:

Answer 7

1) Observations used daily in treatments and help guide on continuing progress.
2) Observation is an important part of your clinical reasoning; you decide how to reach goals.
3) Helps improve your notes, gives clear mental picture of client’s situation and what transpired during the session. (Info to share.)

Question 8

Using your EYES for observation:

Answer 8

• Watch daily activities/ADLs
• See body posture, skin appearance
• Watch breathing patterns
• See BMs/Urine (look for health issues)
• Watch facial expressions/reactions

Question 9

Using your EARS for observation:

Answer 9

• Listen for raspy breathing/coughing/sneezing
• Listen for crying, moaning, yelling
• Listen for communication that is not speech

Question 10

Using your NOSE for observation:

Answer 10

• Breath
• Body odor
• Environment (chemicals? Gas?)
• Urine/BM/Vomit

Question 11

Using your TOUCH for observation:

Answer 11

• Skin temperature
• Skin texture
• Pulse

Question 12

Tips to look out for in Observation:

Answer 12

• Does client guard for pain?
• Is a supportive family member present?
• What is quality of mobility/posture/function?
• Are there cognitive/perceptual problems?
• Is there pain?
• Are there safety issues?
• Are there issues with the environment?
• Is progress being made? (Getting better?)

Question 13

What Domain items affecting ability to engage in occupations are important to consider in documentation?

Answer 13

• OCCUPATIONS: ADLs, IADLs, Rest/Sleep, Educ., Work, Play, Leisure, Social partic.
• CLIENT FACTORS: Values/beliefs, Body functions, Body structures
• PERFORMANCE SKILLS: Motor skills, process skills, social interaction skills
• PERFORMANCE PATTERNS: Habits, Routines, Rituals, Roles
• CONTEXTS/ENVIRONMENTS: Cultural, personal, physical, social, temporal, virtual

Question 14

Swap for professional language:

1. suffers from
2. client did
3. client walked
4. client went up/down
5. wheelchair ambulation
6. gave client
7. showed/helped client
8. made
9. changed
10. looked at
11. put
12. brain-damaged
13. weaknesses

Answer 14

1. diagnosed with; has a diagnosis of
2. client performed/ demonstrated/ engaged in/ worked on
3. client ambulated/ performed functional mobility
4. client ascended/descended
5. performed wheelchair mobility; self-propelled wheelchair; ambulated while pushing wheelchair
6. client was issued/ provided; Administered; Applied; Implemented; Received
7. client was instructed; skilled instruction provided; training provided for…; Recommended
8. fabricated/ customized/ designed/ developed
9. modified/ adapted/ customized/ revised
10. observed/ assessed/ evaluated/ examined/ measured for…
11. positioned; set-up
12. Diagnosed with TBI; Sustained closed head injury; Cognitive impairment/disability
13. Challenges; Delayed skills acquisition