TOPIC 3 : CLINICAL DOCUMENTATION

OT DOCUMENTATION ● Method of stating information provided by the family or

● Shows the clinical reasoning of the occupational therapy caregiver about the client
practitioner, and provides enough information to ensure that ○ Ex. Foster parents report that the child exhibits
services are delivered in a safe and effective manner. excessive energy, constantly running around the house,
and jumping on furniture. They also reported that the
PURPOSES OF DOCUMENTATION child is aggressive towards foster siblings and the family
● Communicate information about the client's history and
pet, and he will not remain seated at meantimes.
experiences, interest, values and needs.
● Report comments from caregiver and other professionals.
● Articulate the rationale of the progression of OT services
○ Ex. Classroom teacher reports significant improvement
and client outcome
in child’s ability to remain seated at desk since
● To provide a clear and chronological record of the client’s
implementing use of sensory-cushion in chair to provide
status, nature of OT service provided, client’s response to
additional proprioceptive input. Child states Ï love the
the intervention and client’s outcomes.
bumpy feel of it!”
● Provide accurate justification for skilled OT service
● To gather information, we have to interview to get the child’s
necessity.
occupational profile
Table No 1. Common Types of OT Documentation
○ We can interview parents, caregivers, teachers, or
TYPES WHAT TO INCLUDE child
Screening Referral Information; Client Information; Brief Table No.2 Occupational Profile (S)
Report Occupational
Profile; Assessments Used and Results;
OCCUPATIONAL PROFILE (SUBJECTIVE PART)
Recommendation ● Chief Complaint ● Developmental Milestones
● Goals of the ● Context of Occupation Performance
Evaluation Referral Information; Client Information;
Parents/Caregiver ○ Physical context
Report Occupational Profile; Assessments Used and
● History of Present Illness ○ Social context
Results; Analysis of Occupational Performance;
○ Maternal History ○ Virtual context
Summary and Analysis; Recommendation
○ Prenatal History ● Performance Patterns
Reevaluation Referral Information; Client Information;
○ Perinatal History ○ Habits
Report Occupational Profile; Reevaluation Results; Analysis
○ Postnatal ○ Routines
of Occupational Performance; Summary and
History/Occupational ○ Roles
Analysis; Recommendation
History
Daily Notes Client Information; Types and approaches of ○ Medical History
interventions, response to treatment, environmental
or task modification, assistive or adaptive devices,
● During the interview, you have to plan out how to structure
training education or consultation provided, and your questions in a way that you would be able to gather
client’s present level of performance these pertinent information
Intervention Intervention Goals; Intervention Approaches and ● Do follow up questions, if needed
Plan/ Plan of Types of Interventions; Service Delivery
Care Mechanisms; Plan for Discharge; Outcome
OBJECTIVE (O)
Measures OCCUPATIONAL PERFORMANCE ANALYSIS
Progress Client Information; Goals; Summary of Therapy ● Performance in Areas of Occupation
Notes/ Report Services Provided; Current Client Performance; Plan ○ Play Participation
or Recommendations ○ Social Participation
Transition Client Information; Client’s Current Status; Transition ○ Activities of Daily Living (Feeding, Dressing, Toileting,
Plan Plan; Recommendations etc.)
Discharge/ Client Information; Summary of Intervention
Discontinuation
○ Instrumental Activities of Daily Living
Process; Recommendations
Report ○ Education Participation
○ Rest and Sleep
SOAP NOTES ● Only include those applicable or expected of your client
● S - Subjective depending on his/her age and specify each area
● O - Objective ● Performance Skills as Related to Client Factors
● A - Assessment ○ Occupation (indicate occupations that the client has
● P - Plan difficulty participating)
SUBJECTIVE (S) Table No.3 Performance Skills as Related to Client Factors
● The therapist records the client’s (parents) report of PERFORMANCE UNDERLYING ACTIVITIES/TASK
SKILLS CLIENT FACTORS DEMANDS AND
limitations, concerns, and problems, as well as what the REQUIRED CONTEXTUAL FACTORS
client (parents) said was relevant to treatment (goals, and ● Motor Skills: ● Body function: ● Objects used and
plans) ● Process ● Body structure: their properties:
● Greater significance to your note if it is specific in nature Skills: ● Space demands:
● May either use a direct quote or summarize what the ● Social ● Social demands:
client(parent) has said: The mother reports that the child is Interaction ● Sequencing and
restless and inattentive at school. Skills: timing:
○ Ex: Student reports frustration with handwriting tasks,
stating “I’m just no good at it. I hate writing!” ● Performance Skills and Client Factors
○ Caregiver reported that the client displays tantrums ○ Motor and Praxis Skills
whenever his wants are not given immediately to him. ○ Sensory-Perceptual Skills
○ The parents mentioned that the child seemed not to ○ Sensory Processing
hear what they say whenever they called him. ○ Cognitive Skills and Executive Functions
○ The child’s teacher reports that the child has difficulty ○ Work Behaviors
finishing his exams and often skips items. ○ Communication Skills
○ Other Significant Findings

1
 TRANS TITLE

● Standardized Test Table No.7 Wiring Problem Statements – Format (B)

○ Administration Client has due to
○ Summary of Results difficulty to
○ Interpretation Engage in what What
occupational task underlying
ASSESSMENT (A) factor
● Appraisal of the client’s functional limitations, progress, and results in
expected benefit from rehabilitation Underlying factor What occupational
● Interpretation of the data presented deficit
○ Based on one’s professional judgment Table No.8 Sample Problem Statements – Format (B)

○ Potential impact on the client’s ability to engage in Client has Initiative due to Age-inappropr
meaningful occupation difficulty in conversation iate social
with peers skills
● In IE, we look into the client’s strengths and weaknesses,
Which results in Limitation in Social participation
prioritized problem list, and rehabilitation potential
● In Progress notes, we take note of the improvements and HOW TO WRITE YOUR PROBLEM STATEMENT
regressions observed during sessions PROBLEM PRIORITIZATION
WRITING PROBLEM STATEMENTS ● Needs to be included in the assessment. You have to create
● The diagnosis is NOT a PROBLEM the PPL: Prioritized problem list.
● Important considerations: GUIDE QUESTIONS
○ Area of occupation that is a concern ● Which problems are appropriate for OT intervention?
● In what order will you work them out?
○ Factors that are interfering with client's engagement in
occupation Factors to consider?
These factors will guide us in creating our problem list. These
■ Performance skills
will also help with justifying the actions to be implemented. This
■ Performance Patterns contributes to our clinical reasoning behind our priorities.
■ Context ● Easiest to address
■ Activity Demands ● Problem skill/behavior that causes the other problems to
■ Client Factors exist
● Immediate need of the patient
COMPONENTS IN PROBLEM STATEMENT
1. Area of Occupation/Task or Activity SAMPLE CASE
L.M. is a 3-year old child diagnosed with ASD. He has fleeting
2. Underlying factor that interferes/impedes
eye-contact, (-) response to name-calling and grabs other’s
a. Performance skills or Performance Patterns hands whenever he needs something. He also has limited
b. Contexts attention span and gets easily distracted. He would shift easily
c. Activity Demands from one toy to another during play. He can do finger-feeding
d. Client Factors but he has difficulty holding spoons, scooping food from plate
3. Assist level needed by the client and bringing food to mouth thus max spillage is observed during
feeding.
Table No.4 Writing Problem Statements – Format(A)
Client in due What are the problems observed? Try to create your own list.
needs to
PLAN (P)
Assist Performing Underlying
Level what factor ● Specific intervention that will be used to achieve goals
occupational ● Should be congruent to the results presented in the
task objective information and assessment
○ Client problems and objectives shall be identified
Table No.5 Sample Problem Statements – Format(A)
during the initial assessment / evaluation.
Client Moderate in Doffing and due Difficulty with
needs Assistanc donning to following ● LTG and STG; frequency and estimated duration of the
e upper body instruction and treatment
garments sequencing LONG TERM GOALS
Client Hand-over in Coloring due Poor grip
needs -hand Activity to strength and ● Outcomes- goal of an intervention
assistanc difficulty ● Also known as “Discharge goals” - what does the client want
e assuming, to achieve after the therapy?
maintaining, ● At least one (1) LTG for each problem; could be one year, 6
and using tripod months etc. depending on the prognosis
grasp ● Time frame may vary
Table No.6 Level of Assistance ● Usually, long term goals are generally written
LEVEL OF ASSISTANCE QUALIFIER ● Sample:
Minimal Assistance 25% of the time ○ Client will be able to complete self-care activities
Moderate Assistance 50% of the time independently within 6 months of OT sessions.
Maximal Assistance 75% of the time ○ Client will be able to improve play participation within 6
Contact Guard Assistance Involves physical cueing months of OT sessions.
(CGA) ○ Client will be able to dress self independently and
Stand by Assist (SBA) For safety; no physical cueing efficiently within 6 months of OT session.
SHORT TERM GOALS
● Daily goals/session goals
● Incremental/sub-steps (smaller steps) toward achieving LTG

2
 TRANS TITLE

● Can have several STGs for an LTG ● You can rearrange COAST as well.
● Time frame is shorter ○ Within 3 OT sessions, client will feed self 50% of meal
● Sample: using built-up spoon with min
○ Possible LTG for the following STGs: Dressing ○ physical (A) to scoop.
Independently ○ Using a built-up spoon, the client will feed self 50% of
○ Client will be able to correctly identify orientation of the meal with min physical (A) to scoop within 3
shirt 50% of the time given minimal verbal reminders in sessions.
2 OT sessions. QUALITIES OF A GOAL
○ Client will be able to don garterized lower body
garments given minimal assistance in 2 weeks of OT SMART method RHUMBA method
sessions. Specific Relevant
Measurable How long?
GOAL WRITING: COAST METHOD
Attainable Understandable
To check the quality of our goal statements, we use the COAST
Method: Realistic Measurable
● C- Client (Client will perform) Time Bound Behavioral
● O- Occupation (What occupation?) Attainable
● A- Assist Level (With what level of Table No.10 Evaluating Goal Statements: SMART Test
assistance/independence?) SMART Evaluation
● S- Specific Condition (Under what conditions?) Significant ● Will this goal make a significant difference in
● T- Timeline (By when?) the client’s life?
● Is this what my client wants or needs?
CLIENT (C) Measurable ● Does this denote a clear target to aim for?
● Goals should be written in terms of what the client will do, ● Will I know if and when the client gets there?
not what the therapist will do. Achievable ● Can this be reasonably achieved within the
● Action verb is inserted here: perform, demonstrate, or time frame?
complete Related ● Does this goal have a connection to the client’s
● Example: occupational needs?
● Do LTG and STG relate to each other?
○ Client will be able to.....
Time Limited ● Does this goal have a chronological end point?
● You can also use names, for example: ○ LTG met - discontinue
○ Sam will be able to..... ○ STG met - new STG
OCCUPATION (O) ○ STG not met - modify or continued
● This is the specific occupation to which the goal pertains Table No.11 Evaluating Goal Statements: RUMBA Test
and should relate to the problem statements that have been SMART Evaluation
established. Relevant ● Is this something I would see my client doing
● Example: when he is discharged?
● Is this something beneficial for my client in
○ Client will be able to don garterized lower body performing occupations?
garment... Understandable ● Would the client be able to know what he or
ASSIST LEVEL (A) she is able to do when he or she reads the
● This is where you specify the level of assistance expected, objective?
● Would other practitioners know what is
which ultimately translates into the level of independence
intended to be achieved when reading the
that the client is expected to demonstrate. objective?
● Be careful not to mix level of assistance ● Will I know if and when the client gets there?
● Example: Measurable ● Is there a way that I can clearly identify if the
○ Client will be able to don garterized lower body client did or did not successfully meet the
garment given minimal assistance....... objective?
Behavioral ● Is the goal written in a manner that will allow
SPECIFIC CONDITIONS (S) the expected performance to be clearly
● Specify any other conditions under which the client is observed?
expected to perform the desired action such as location, ● Is the goal action oriented?
adaptive equipment, or modified technique Achievable ● Is the goal realistic within the time frame,
● In rare cases, it is acceptable to omit either the “A” or the demands, and resources?
“S,” but never both. ● Is the goal realistic in my setting in relation to
● Example: the client’s level of ability?
○ Client will complete all dressing tasks (I) by discharge. FEAST METHOD
○ (I) - Independently
Function ● Specific area of occupation
TIMELINE (T) ● Essential focus of the goal statement
● The time frame within which the goal is expected to be Expectation ● Client is the key player.
accomplished. ● Set the expectation.
● Timeline for STGs may be weekly, daily, or by number of Action ● Clients goals, client-oriented
sessions. ● Action verbs
● Example: Client will be able to don garterized lower body Specific ● Necessary for the behavior to occur
Condition ● Level of Assistance/Cues/Prompts/Supervision
garment given minimal assistance within 2 weeks of OT ● Equipment; Environmental Modifications
session. Timeline ● When the goal is expected to be accomplished
EXAMPLE OF GOAL STATEMENT
● C: Client will EXAMPLES OF LTG AND STGS
● O: feed self 50% of meal Problem: Client has difficulty waiting for instructions, waiting for
● A: with min physical (A) to scoop his turn to speak and focusing on therapist-initiated activities
● S: using built-up spoon due to poor work behaviors resulting in problems
● T: within 3 OT sessions. in Play Participation.

3
 TRANS TITLE

LTG: Client will be able to improve work behaviors specifically

impulse control and concentration after 6 months of OT session.
● Impulse control problem: it’s very clear that there’s a
problem in waiting for
● instructions and waiting for turn to speak which is PRACTICE
translated to difficulty or problem in impulse control Write measurable, functional, time limited, realistic goals for the
● Focusing on therapist-initiated activities: about scenarios below:
concentration 1. Mary is not able to attend to her coloring task, which
● This is how we translate, more specific
makes school activities difficult for her. You would like her
After 2 months of OT session, the client will be able to: to attend to a task for 10 minutes by the time she is
STG1: Finish therapist-initiated activities without getting
discharged 2 weeks from now.
distracted given moderate verbal and physical prompts and
environmental modifications; 2. Ana cannot finish her seatwork at school because she
finds it hard to follow the instructions. You would like Ana
STG2: Wait for instructions given moderate verbal prompts;
STG3: Wait for his turn to speak given moderate verbal to be able to follow 1- step instruction with 4 critical
prompts elements after 3 weeks of OT session.
TREATMENT PLAN
FRAME OF REFERENCE QUIZ
1-2.Identify Significance the level of assistance
● Should be identified (and well justified)
a. 25% of the time
● The FOR should be easily identified in the entire plan
b. For safety purposes; no physical cueing
● TYPES OF INTERVENTION
3. T. or F. In writing problem statements, the diagnosis of the
TYPES OF INTERVENTION child is a problem.
● TUA (TOP DOWN) 4. T or F. Standardized Tests are included in the Occupational
○ Preparatory Methods, Tasks Performance Analysis
○ Activities 5. T or F. General information about the client provides the
○ Occupations greatest significance in taking notes.
○ Education and Training 6. T or F. All common types of OT documentation require client
● TUA (TOP DOWN-PEDIA) information.
○ Behavior Modification Techniques - (e.g. 7. T or F LTGs are also known as discharge goals.
reinforcements, behavior chart/behavioral contract, 8. T or F Plans are the specific interventions used to achieve
etc.) goals
○ Environmental Modification Techniques - positioning 9. T or F There could only be one STG for an LTG
and presentation of task objects, etc. 10. Identify: time frame within which the goal is expected to be
○ Language Facilitation Techniques Accomplished.
● TUG (if necessary)
(1) Minimal Assistance (2) Stand by Assist (SBA) (3) F (4) T (5)
F (6) F (7) T (8) T (9) F (10) Timeline

●
●

4
TRANS TITLE