OTH 209 Week 4 – Writing SOAP Notes

Documentation is essential for:

o Communication among healthcare professionals. o Legal records for malpractice, fraud, and negligence. o Reimbursement from insurance providers. o Tracking progress and guiding client care. • Must be accurate, timely, and confidential (AOTA, 2020)

Documentation is read by various professionals, including:

Medical professionals (doctors, nurses, PTs, SLPs, etc.).

o Education professionals (teachers, school administrators).

o Legal professionals (lawyers, judges). o Accreditation agencies (The Joint Commission, CARF).

o Payers (Medicare, Medicaid, insurance providers). o Clients and their guardians.

Documentation Tips

Use correct grammar, spelling, syntax, and word choice. • Follow directions carefully and use writing resources. • Proofread multiple times to ensure accuracy. • Legibility is key (if handwritten).

Describing Clients Professionally

Use appropriate terminology for gender, pronouns, disability, race, ethnicity, and age. • Follow person-first language

Legal & Ethical Considerations

Malpractice, fraud, negligence, or incompetence. o Ethical violations (AOTA’s Standards of Practice

Practitioners must:

Maintain complete, accurate, and timely records. o Avoid falsifying or plagiarizing documentation

Importance of Documentation in Clinical Settings

Ensures continuity of care across shifts and disciplines. • Provides a chronological record of client care. • Serves as a legal document and supports reimbursement

Essential elements of OT documentation:

Date of report completion. o Full signature & credentials of the practitioner. o Client name & case number. o Standardized abbreviations & terminology. o Confidential storage & disposal of records.

HIPAA compliance is crucial for protecting client data. • Guidelines include:

Always log in & out of systems. o Never leave a computer unattended. o Access is restricted to necessary personnel. o Audits are conducted to monitor security.

Documentation of Telehealth

Telehealth documentation follows the same rules as in-person care. • Must specify: o Use of telehealth technology

Documentation in School Settings

Required consent forms for working with minors. • Includes: o Individualized Family Service Plan (IFSP) (ages 0–2). o Individualized Education Program (IEP) (ages 3–21)

Notice & Consent in Schools

Schools require notice & consent forms for: o Team meetings. o Evaluations & re-evaluations. o Referrals & procedural safeguards. o IFSP & IEP documentation.

IFSP Documentation (Ages 0-2) • Documents early intervention services for infants & toddlers

Current level of performance. o Family’s concerns & priorities. o Goals & service plans (frequency, intensity, and setting). o Steps for transitioning to preschoo

IEP Documentation (Ages 3-21)

Documents OT services provided in schools. • Must include: o Present educational performance. o Annual goals & special services. o Participation in standardized testing. o Transition planning (starting at age 14). o Measurement of progress.

Documentation in Emerging Practice Settings

OT is expanding into community-based settings (e.g., homeless shelters, prisons, hospice). • Documentation may be different: o Often organization-focused rather than clinical. o Must still align with AOTA guidelines

Common Documentation Mistakes

Not using time efficiently (writing too much or too little). Failing to connect activities to client goals (focus on occupation-based treatment). Using incorrect abbreviations or terminology (follow facility guidelines). Writing in passive voice (*use "Client participated in…" instead of "Client was

S = Subjective

Client’s perspective about their condition or therapy. • Not measurable or verifiable. • Can be a direct quote or a summary. • Examples: o “My wrist hurts when I try to lift my coffee cup.” o Parent reports: "She refuses to put on socks because they feel weird.

O = Objective

Measurable, quantifiable, and observable data. • Step-by-step process: o Start with session details (time, setting, purpose). o Summarize key client deficits impacting performance. o Describe observations (organized chronologically or categorically). • Examples: o Client participated in a 30-minute OT session in a rehab gym focused on improving self-feeding skills. o Patient required minimal assistance to grasp and lift a spoon during meal prep

A = Assessment

Interprets data from S and O sections. • Does not introduce new information. • Uses clinical reasoning to highlight: o Problems (e.g., safety risks, functional limitations). o Progress (e.g., improved endurance, reduced pain). o Potential (e.g., client’s motivation for rehab).

P = Plan

Outlines next steps for therapy. • Should be clear and actionable. • Includes: o Frequency & duration (e.g., 2x/week for 6 weeks). o Specific interventions (e.g., strengthening exercises, adaptive training).