Why is documentation important in occupational therapy?

Why is documentation important in occupational therapy?

OT practitioners spend lots of time on documentation. Our notes help us track patients’ progress, communicate with other healthcare providers, and defend our rationale for our treatment choices. Documentation is a key factor in our patients’ well-being during their continuum of care.

What is the purpose of documentation in occupational therapy?

Occupational therapy documentation reflects the nature of services provided, shows the clinical reason- ing of the occupational therapy practitioner, and provides enough information to ensure that services are delivered in a safe and effective manner.

What is the goal of the occupational profile?

The occupational profile helps create a summary portrait of a client viewed as an occupational being, organizes the evaluation around the activities the client wants to do but has difficulty with or cannot do, and frames the process of inductive reasoning.

What should be included in occupational profile?

“The occupational profile is a summary of a client’s (person’s, group’s, or population’s) occupational history and experi- ences, patterns of daily living, interests, values, needs, and relevant contexts” (AOTA, 2020, p. 21).

What are the key components of physical and occupational therapy documentation?

Access the main documentation elements are: initial examination and evaluation, visit, reexamination, and conclusion of episode of care summary. There are many elements of documentation that need consideration; one of the most important is clinical setting.

What is defensible documentation?

Defensible documentation demonstrates compliance with local, state, federal, and payer regulations. Third-party payers often use your documentation to determine appropriate payments. In legal situations, your notes act as a historic account of patient encounters.

What is documentation in occupational therapy?

The purpose of documentation is to. • Communicate information about the client from the occupational therapy perspective; • Articulate the rationale for provision of occupational therapy services and the relationship of. those services to client outcomes, reflecting the occupational therapy practitioner’s clinical.

What is professionalism in physiotherapy?

Background: Professionalism is defined by the Chartered Society of Physiotherapy (CSP) as “the qualities, skills, competence and behaviours expected of individuals belonging to any given profession including physiotherapy”. Physiotherapists are governed by the Health Care Professions Council.

What is the concept of professionalism?

“The skill, good judgment, and polite behavior that is expected from a person who is trained to do a job well” Merrium-Webster, n.d. “’Professionalism’ is commonly understood as an individual’s adherence to a set of standards, code of conduct or collection of qualities that characterize accepted practice within a …