According to the AOTA, the following should be documented for the intervention:
Intervention Plan
- Client information – demographic, precautions, contraindications
- Intervention Goals – measurable, meaningful, occupation-based, short- and long-term goals
- Intervention approaches and type of interventions to be used
- Service delivery mechanisms – provider, location, frequency, duration
- Plan for discharge – criteria, setting, follow-up, referrals
- Outcome measures – standardized or nonstandardized, should conform with the payer source and facility’s requirements
- Professionals responsible and date of plan – who oversees the plan
Service Contacts
Contacts between the client and occupational therapy practitioner. Include the types of interventions used and, the client’s response.
- Client information
- Therapy log – summary or significant information of client attendance, participation, reason service is missed, interventions used, response, environmental or task modification, adaptive devices used or fabricated, training, education, consultation, and services provided.
- Intervention/procedure coding, e.g., CPT (if applicable)
Progress Report/Note
Summarizes intervention process and document’s client’s progress toward goals. include any newly collected data, modifications, statements of need, discontinuation (D/C), or referral.
- Client information
- Summary of services provided
- Current client performance
- Plan
Transition Plan
Documents the formal transition plan from and to where.
- Client information
- Client’s current status
- Transition plan – service setting, reason, time frame, and activities to be carried out
- Recommendations – for OT services, modifications, accommodations, and assistive technology.
References
Clark, G. F., & Youngstrom, M. J. (2013). Guidelines for documentation of occupational therapy. The American Journal of Occupational Therapy, 67(6), S32.