Documentation Fundamentals

OT Dude Academy’s Free NBCOT® Exam Prep Course Process Documentation Fundamentals
  1. Client’s full name
  2. Case number or medical record number on each page
  3. Dated (include full year, YYYY, to avoid ambiguity)
  4. Chronological (if on paper)
  5. Type of documentation (e.g., evaluation, progress note)
  6. Signature – first name and last, initial, professional designation
  7. Co-signature for OTA or students
  8. Compliance with laws, regulations, and facility requirements
  9. Acceptable terminology for the setting
  10. Abbreviations acceptable for the setting
  11. Note and sign all errors
  12. Do not use pencil whiteout or nonpermanent ink
  13. Dispose of records within law or facility requirements
  14. Compliance with confidentiality standards, e.g., HIPAA
  15. Reflect the professional reasoning and expertise of an occupational therapy practitioner and the nature of services provided
  16. Write concisely
  17. Be specific
  18. Double-check for spelling, grammar, and errors
  19. Include units of measurement where applicable, e.g., pounds vs. kilograms
  20. Use recommended terminology such as pronouns for the setting
  21. Include only pertinent subjective data
  22. Document in a timely manner
  23. Avoid documenting legal matters in the chart
  24. Informed consent should be documented and included in the record
  25. Blank spaces should be filled in with no lines or spaces skipped (similar to writing a check)
  26. Late entries are less credible and may draw attention to areas of weakness (Bean, 1993)
  27. Avoid documenting in the record that an incident report is on file
  28. Use ‘SLIDE’ for corrections – a single line through the error, initials, date, and explanation of why the correction was made (Baker, 2000)
  29. Never alter or change a record, in contrast to making corrections for mistakes

References

Baker, S.K. (2000), “Minimizing litigation risk. Documentation strategies in the occupational health setting”, American Association of Occupational Health Nurses Journal, Vol. 48 No. 2, pp. 100-5.

Bean, R.V. (1993), “Altering records: discrediting your best witness”, Journal of the Medical Association of Georgia, Vol. 82 No. 2, pp. 63-4.

Clark, G. F., & Youngstrom, M. J. (2013). Guidelines for documentation of occupational therapy. The American Journal of Occupational Therapy, 67(6), S32.

Kebede, M., Endris, Y., & Zegeye, D. T. (2017). Nursing care documentation practice: The unfinished task of nursing care in the University of Gondar Hospital. Informatics for Health and Social Care, 42(3), 290-302.

Knutson, D., Koch, J. M., & Goldbach, C. (2019). Recommended terminology, pronouns, and documentation for work with transgender and non-binary populations. Practice Innovations, 4(4), 214.

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