Documentation and Writing Goals Flashcards
Types and formats of documentation
Documentation types and format will depend on the setting in which the services take place
The documentation approach may also vary depending on the team approach
Type of documentation used is usually driven by the third-party payer., the intervention setting, and the patient population
Specific types of documentation
Screening note
Contact note
Screening note
A quick hands-off chart review, interview, and observation of client in order to determine if full evaluation is needed.
No referral or billing required.
Brief note/specific screening form to either state
- Further evaluation not recommended or
- Request for referral and evaluation
Contact note
A brief narrative note containing the time spent with the client, the reason, and the type of screening
- To communicate referral was received, evaluation/discharge note completed, or reasons why not completed
- To document screening
- Document all contacts with client and family
- Missed sessions/refusals
- To state evaluation was completed
- Equipment given/splint fabricated and instructions issued
- Any other pertinent issues that may occur between intervention sessions
Format for contact notes: Evaluation report
After referral received, the therapist may begin the process of gathering data through documentation review, observation, interview, and full hands-on assessments.
Data is interpreted, documented, goals set with timeframe, and full intervention plan/recommendations communicated.
Precautions and contraindications are highlighted along with the client’s goals/expectations.
Format for contact notes: Intervention report/ progress note
Typical components of the intervention may include
- The date/time
- Types of interventions: methods, modalities, group/individual, strategies, activities, adaptive equip, techniques used during session
- Length of session
- Progress towards goals w/updates/changes
- Client’s response to intervention
- Comparison with previous reports and status
- Timeframe changes and recommendations
- Equipment recommendations
- Home program
- Caregiver instructions
- Plan/discharge w/revised goals and plan
Format for contact notes: Re-evaluation report/ note
Informal and formal re-evaluations occur as an ongoing process. The forms used to complete re-evaluations will be conducted according to the facility’s policy, as well as third-party payer needs. They may include:
- Data recorded and reported regarding reassessment
- Comparative analysis of findings and summary
- Modification of goals
- Update plan
- Need for discharge
Format for contact notes: Discharge note/discontinuation summary
D/C may be due to the client achieving set goals or maximum benefits of therapy, insurance caps, or the client refusing to participate in therapy. Summary involves a review of the OT assessment, intervention, and outcome. It summarizes the client’s evaluation/intervention processes from beginning to end. Components of a D/C note should include:
- The beginning and end date of services
- The therapy process/summary of intervention strategies
- Re-eval, goal status, attainment, progress in therapy, why goals not achieved
- Functional outcome of services
- Number of completed sessions
- Home programs, maintenance programs & caregiver instructions
- Recommendations/equipment needed
- Follow-up plans and/or referrals
- Client’s assessment of efficacy of OT
Format for contact notes: M.D. Report
Reports sent to the physician regarding the client’s progress either on a monthly basis or with each scheduled visit. The format depends on where the client is within the intervention process. Certain physicians may have a specific format that is required or desired.
Formats of documentation
SOAP Note
DAP Note
Narrative Note
Flow Sheet/Checklist
Computerized Forms
SOAP note
A very well known form of progress note. This format provides a consistent structure for all disciplines to follow.; it allows for a quick review of the client’s status prior to intervention.
S – subjective: the client’s report/perceptions of the problem. “Client stated…” or “Client reported…”
O – objective: consists of factual or professional information that is confirmed or validated by the therapist. Baseline data and or progress goals, observations, and client performance may be included. Data is NOT interpreted here. “Client was seen for…, or the intervention consisted of…,” then a chronological listing of the interventions participated in.
A – assessment: directly related to the subjective and objective sections. The therapist’s professional opinion and analysis are documented. Includes clarification of client goals and problems, the therapist’s rating of client progress. The subjective and objective data may be interpreted and a prioritized list of problems to be addressed developed.
P – plan: specifies the type, frequency and duration of interventions to use in the next session and/or in response to progress or lack thereof. Updated goals can be listed here. D/C and home programs included here.
- Enough info should be here if a substituting therapist takes over the next session.
DAP note
This format includes a description, assessment, and plan. It is not as frequently used
D – the findings section (combined subjective and objective components from a SOAP)
A – documents exactly the same info as the assessment in a SOAP
P – same information as the plan in a SOAP
Narrative note
Narratives do not have a specific “structure.” The narrative tells a story that allows for more flexibility in communicating information
Flow sheet/ checklist
Several advantages to using flow sheets:
- Concise format for tracking progress
- Allows quick look at documentation format
- Allows for easy coverage of client’s care
Disadvantages include:
- Limited space for documenting psychiatric issues, descriptions, or client reactions that are necessary for holistic client-centered interventions
This format cannot replace progress notes
Computerized forms
Many facilities use computers for documenting evaluations, interventions, and discharge summaries.
What is an EHR?
- An electronic health record in widely used for documentation by health care organizations.
Common terminology
Abbreviations
