Types of documentation - from dl2 practice

Transition plan

Documents the formal plan to support the client from one service setting to another within a service delivery system

screening report

Documents the referral source and the reason for occupational therapy screening

discharge report

Documents the plan to support the end of the client’s occupational therapy services

reevaluation report

Conducted when new findings emerge, a change in the client's condition warrants further testing, or when required by payer or facility

intervention plan

Documents the goals and the intervention types and approaches to be used in the occupational therapy process on the basis of the results of evaluation or reevaluation processes

evaluation report

Documents the referral source and data gathered through the occupational therapy evaluation process

progress report

Documents a summary of the contacts between the client and the occupational therapy practitioner, the goals and the intervention types and approaches used in the occupational therapy process, and the therapy outcomes in accordance with practice guidelines and payer, facility, and state and federal guidelines and requirements

daily treatment note

Documents the contacts between the client and the occupational therapy practitioner, the goals and the intervention types and approaches used in the occupational therapy process, and the therapy outcomes