Struggling with what to document and how to do it in a timely manner?
Suppose you are an occupational therapy student going into fieldwork, a brand new Occupational Therapist trying to get into hand therapy, or potentially even an Occupational Therapist with a lot of experience trying to get into hand therapy.. these are a few questions I’m going to be going over.
So the first question is, for documentation as an expert, where have you seen the most common mistakes?
A common mistake when it comes to documentation is that you have taken too long to write it.
If you are taking hours and hours to write something, that is a serious mistake. So there is something to be said about time management when it comes to documentation.
When it comes to documentation and time management, the most important thing is that you’ve got to plan ahead if you have so many X patients a day. Some of you might be working with four or five patients per hour a day and that’s really, really hard. I’ve been there, done that. But you definitely have time between sessions or as someone is doing something like on a hot pack or cool pack or you know, in an activity or an exercise that they’re able to do a little bit on their own, you can do some documentation.
Something I think is more about just practice is getting the patient’s history. This is what you’re doing like an eval and you have the S, the O, the A, and the P. The history is in the S – What happened to them? And the biggest thing is just keeping it really, really simple. Try to summarize and write it in the most simple way and use an abbreviation that obviously depends on the place. Certain abbreviations are pretty standard, so you just want to say, let’s say, for example, the patient is a right-hand dominant male injured left, small finger at work.
When getting a patient’s history,think ahead about, “what are some of the key tidbits of information I need to know?”
You need to know their hand dominance and need to know the injury that they had. You can even say “patient is a right-hand dominant male injured at work”, then you write the history and then you say, status post, ORIF small finger. Left small finger.
Now obviously, if it was the one time, it’d be a great, super easy history. The ones that are a little bit more complex are if they’ve had months of therapy before, patient injured hand at X date.
Write “Had surgery and went to therapy for X amount of time, but still had residual or went and had a second surgery and now returning. Patient here for OT/CHT services.”
Then you could fill in the blank for decreased range of motion, increased pain, wound care, all that stuff.
The objective portion is the most important numbers.
In documentation, if you think about it, it’s all about covering your ass. It’s all about why someone should pay you to provide therapy services. If you work with insurance companies, you’re always justifying to a third party to say why they’re paying for occupational therapy services for this person.
I still document no matter who the payor is but if it’s a cash patient, I justify it to the patient. I don’t justify it to this third-party payer if that makes sense. If it’s a cash patient, I’m talking to them and I justify it to them only. But if it’s to insurance or workers’ comp, you have to justify it to everybody.
If you’re seeing Medicare or Medicaid patients, you’re justifying it to the federal government. You know you need to write why they’re there and why they need to be seen by you. And then your objective is all your measurements.
Do you have to have every single measurement that same day? You might not be able to, especially in complex cases. But you’re trying your best, you pick the most important thing that you need to measure that day and measure it. Whether it’ll be a hand, sometimes you can’t really measure if they’re only passive range of motion. So you’re picking out the most important things like where does their PIP extension end? What’s the position of the wrists? That kind of stuff.
Your assessment is the most important summary of why they need you.
If you’ve written the history of what happened to your patient, your assessment part is going to summarize why they’re here in therapy. This is where you’re kind of justifying it. You’d write, “Patient would benefit from OT/CHT services for X, Y, Z to return to prior level of function.” Or to return to whatever type of work, whatever type of hobbies.
I’ve got a guy, he’s got elbow pain. His goal with me is to help him to be able to do push-ups and get back into martial arts. I would write “Patient would benefit from OT, CHT services to get rid of elbow pain to be able to participate in workouts and martial arts type of activity.”
If I have a worker’s comp person, for example, A flexor tendon. I may write “Patient would benefit from OT/CHT services, to increase motion, reduce any risks associated with flexor tendon types of injuries, types of surgeries to return to prior level function.”
If they are a complex case, you’d write that the patient presents with severe complex cases of such and such to a late flexor tendon repair and he would benefit from OT/CHT services. Patient presents with decreased range of motion, increased pain, and decreased function after a distal radius fracture and would benefit from OT/CHT services to return to prior level of function so that she could go back to work full time, full duty, without restrictions.
So you can say it in your own way, but you’re getting the history and you are telling someone why they’re coming to you, why OT, and then you take the measurements so that you could compare to later. And then your assessment here is you essentially summarizing again to justify the why.
The plan supports your history, your objections, and your assessment.
And then you create the plan – how frequently will they come to see you and for how long. This is based on their severity and how committed they are about getting the best results. There ae several other aspects when creating a plan – but the most important aspect is your patient.
In a nutshell, when it comes to documenting as an Occupational Therapist, you should be thinking about:
- Justify the therapy – why they need you.
- Show proof – where they started and how they are improving.
- CYA – Cover Your Ass – what you need and the response.
Hope these tips help you manage your time better when it comes to documentation and know what to write so that it does not take you so long to complete your documentation.
If you don’t feel confident about what to say to your patients or feel uncertain that you are providing the right treatments and recommendations. Get the skills and confidence you deserve to advance your career, help any patients that come your way, and feel sure about what to do and what to say.