60 Tips to Improve Your Documentation as an Occupational Therapist

Documentation in healthcare can be a stressful task for many healthcare providers, as it can take away from the time spent with patients and can feel like a burden. Many healthcare providers feel that they don’t have enough time to complete documentation, as it can take away from the time spent with patients. Some occupational therapists find it overwhelming to keep up with the amount of paperwork that is required in healthcare, especially with the increased use of electronic health records (EHRs). OTs may be worried about making mistakes in documentation, which could lead to legal and financial repercussions. Some may not have received adequate training on how to document properly, which can make the process more stressful. Constant interruptions during the documentation process can make it difficult to complete the task efficiently. Some healthcare providers may find that the documentation process is not meaningful and that it doesn’t contribute to the overall care of the patient.

To reduce the stress associated with documentation, healthcare providers can implement strategies such as using technology to streamline the documentation process, providing training and education on documentation best practices, and implementing standardized documentation protocols. Additionally, they can use speech recognition technology and other tools to make the process faster and more accurate.

Here are 60 tips to help you become better and more motiviated with documentation as an occupational therapist:

  1. Adopting electronic health records (EHRs) to increase efficiency and reduce errors. This may depend on your employer, but if you are self-employed, consider this option.
  2. Implementing standardized documentation protocols and templates to ensure consistency and completeness. This makes you work much faster and consistently.
  3. Providing training and education for healthcare providers on proper documentation techniques and best practices. This applies to those who are more experienced or mentoring such as with fieldwork.
  4. Incorporating speech recognition technology to reduce the need for manual entry and improve speed and accuracy. Other types of technology also may help.
  5. Regularly reviewing and updating documentation to ensure it is accurate, up-to-date, and complies with regulatory standards. Do this during downtime.
  6. Encouraging open communication between healthcare providers to ensure all relevant information is captured in the patient’s record. Communication leads to better outcomes and makes documentation more streamlined and consistent across the EMR for patients.
  7. Making it easy for patients to access their medical records online, which can help improve their engagement with their care and reduce errors. Education is also part of this process.
  8. Making sure the documentation is easily understandable and readable by the patients to ensure they understand their medical conditions and treatment plan. Don’t use overly complex language if you do not have to – it takes more time to think of these words and terms in the first place.
  9. Leveraging machine learning and natural language processing to improve the quality and efficiency of documentation. Don’t be afraid to use newer technology.
  10. Use standardized assessment tools and forms to ensure consistency and completeness of information. It may be an upfront cost, but is well worth it in the future.
  11. Use clear, concise language and avoid overly-technical medical jargon when documenting progress and treatment plans.
  12. Include measurable goals and objectives that are specific, realistic, and achievable.
  13. Use appropriate acronyms and abbreviations but make sure they are defined and consistently used throughout the documentation. Don’t use ones that are not recognized…YMMV.
  14. Document progress and outcomes in a timely manner, including any changes in the patient’s condition or treatment plan. Don’t do it at the end of the day as you will likely forget small details, or even worse, confuse patients for each other.
  15. Use the SOAP (Subjective, Objective, Assessment, and Plan) format for progress notes to ensure all relevant information is included. Other strategies exist as well.
  16. Include all interventions and modalities used during the therapy session and document the patient’s level of participation and progress. Write down the most important things.
  17. Document any communication with other healthcare providers, including referrals, consults, and discharge planning. This helps to cover your bottom.
  18. Use appropriate codes and billing information to ensure compliance with insurance and reimbursement guidelines. Refer to your guides or management if you need help.
  19. Regularly review and update documentation to ensure it is accurate, up-to-date, and complies with regulatory standards.
  20. Use technology to enhance documentation and reduce errors such as spellcheck.
  21. Incorporate patient feedback and input into the documentation, as this can provide valuable insight into their progress and treatment needs. Don’t forget about the patient.
  22. Use visuals and diagrams to supplement written documentation, such as drawings or photos of the patient’s work or home environment. Canva can be your friend.
  23. Include a summary section at the end of each progress note to summarize the patient’s progress and next steps. This makes it easier for other therapists to read as well.
  24. Keep the documentation legible and organized, using headings and bullet points to make it easy to read and follow. For those of you who are still using paper and pen.
  25. Document any relevant information about the patient’s medical history and any co-occurring conditions that may impact their occupational therapy treatment such as in the evaluation.
  26. Document any modifications or accommodations made to the patient’s environment or equipment to support their participation in therapy. This ensures continuity of care.
  27. Be mindful of patient privacy and confidentiality when documenting, and ensure that any sensitive information is protected. HIPAA.
  28. Stay updated with the latest regulations and guidelines for documentation in occupational therapy and make sure to follow them consistently. Things change, such as with COVID-19.
  29. Be consistent with the documentation format and style, this will help other healthcare providers to understand the patient’s progress and treatment plan more easily. Don’t change things up too much or you may throw your team off.
  30. Use the correct terminology and language when documenting the patient’s condition, progress and treatment plan. This can be embarrassing if you misuse terms or use them even inconsistently.
  31. Use a multidisciplinary approach when documenting, this will help to ensure that all aspects of the patient’s care are considered. Think about who reads your notes.
  32. Think about what you are going to write as you walk to the computer or desk.
  33. Use a patient-centered approach when documenting, this will help to ensure that the patient’s goals and needs are at the center of the treatment plan. Not a therapist-centered note, but a patient-centered one, if that makes sense.
  34. Have a system in place for tracking patient’s progress over time, this will help to identify any areas where the patient may need additional support or interventions. It can be simple and need not be overly-complex.
  35. Always make sure to document any changes or updates to the patient’s treatment plan, this will help to ensure that the patient receives the most appropriate care. It takes a second, but is important to see overall outcomes.
  36. Use technology such as telehealth tools to document and track progress during remote sessions. Be aware of limitations in this technology.
  37. Use multimedia such as videos and images to document the patient’s progress and engagement. Don’t be afraid to enrich learning with these methods.
  38. Incorporate outcome measures to track the patient’s progress and document the effectiveness of the interventions. This makes it more objective and less subjective.
  39. Use shortcut keys, templates, and tricks that are built into the software or operating system.
  40. Use a multidimensional approach to document the patient’s progress, including physical, cognitive, emotional and social aspects. Think OTPF.
  41. Avoid documenting when stressed, thirsty, tired, etc. Take a walk, breathe, or get some fresh air.
  42. Improve your words per minute (WPM) with typing games or consider using dictation software.
  43. Use stick notes on your computer desktop (virtually) or post-it to reference templates and other references you frequently use.
  44. Use online calculators like the OT Dude ones.
  45. Use a team-based approach to document progress, this will help to ensure that all team members are aware of the patient’s progress and can collaborate effectively to provide the best care possible.
  46. Keep in mind the regulatory and compliance requirements such as HIPAA, when documenting to ensure that all records are kept secure and confidential. This includes passwords and other login concerns; social-engineering.
  47. Document any challenges or barriers that the patient may be facing, this will help to identify potential solutions and support the patient’s progress.
  48. Use the latest research and best practices in occupational therapy to inform and guide the documentation process. Google Scholar is your friend.
  49. Find a quiet space to document from distractions or post-up a sign.
  50. Make sure that the documentation process is efficient and streamlined, this will help to ensure that documentation does not take away from the time spent with the patient.
  51. Use a narrative format when documenting progress notes, this will help to provide a more detailed and accurate picture of the patient’s progress. Chronological also makes sense too.
  52. Use technology such as mobile apps to document progress during sessions and make it easy to access patient data. Check to make sure they are approved first.
  53. Use data visualization tools to help analyze and present patient progress data (advanced).
  54. Use a patient portal to allow patients to access their medical records and provide feedback on their progress.
  55. Document any community resources and support services that were recommended to the patient, this will help to ensure that they have access to the resources they need to continue their progress outside of therapy sessions. This can also be done with the discharge note.
  56. Look at other therapists notes and take bits of what you think helps.
  57. Re-read your own notes and look for simple things that can be omitted.
  58. Document any safety concerns or risks related to the patient’s occupation or daily activities, this will help to ensure that the patient is safe and protected. Safety. Safety. Safety.
  59. Consider professional insurance to protect you from errors and omissions and other issues related to documentation. It’s honestly not that expensive in the grand scheme of things.
  60. Write concisely and to the point. This also helps save you time to free up and treat and work with more patients.

Effective documentation is an essential part of providing quality occupational therapy care. It helps to ensure continuity of care, regulatory compliance, and effective communication among the multidisciplinary team. It is important to use best practices and guidelines when documenting and to continuously review and update the documentation process to ensure that it is effective and efficient. Practice makes perfect and the more you document and find what best works for you, the better you become. This comes with a willingness to learn, experiment, and to ask for advice and to take some criticism.