Documenting Occupational Therapy
Yesterday our almost a year long education for new assessments (such as the MOHOST = The Model of Human Occupation Screening Tool) ended with a bang! With a bang because I thought it was the single most efficient day within the education. All was pulled together and I really feel like I’ve finally taken some steps forward. Now we also have a process model for the ot evaluation process in the Health Care Center of Helsinki, Rehabilitation Unit which I think is major. Had some fiery debate regarding it before everyone was satisfied… 😉
Anyway, we were also handed a paper about OT documentation which I think has some brilliantly important points as in what to focus in when documenting. The paper has been translated and put together by Riitta Keponen (OtM). Here are the key points:
- an occupational therapist should recognize and document the meaningful occupations for the client and base both the long and short term goals on the strengths and limitations in those (Mc Guire 1997)
- besides documenting the goals it’s crucial to document how the therapy effects the client’s occupational status (Cederfelt et al. 2003)
- the summary of the report should be put together in a way that the reader gets an impression of a form of therapy which requires expertise and skill (Mc Guire 1997)
- Mc Guire suggests that it would be wise to document the plan for evaluation, interventions, the guidance given and the collaboration with other professionals included in the situation as well as the recommendations
- Both Mc Guire and Cederfelt (et al.) state that an OT should learn to document orientating in effectiveness rather than orientating in procedures. Ots should not document a list of helping aids or solutions but to describe how they effect the occupational performance and participation of the client.
Would gladly hear about your opinions regarding documentation. Please share your thoughts in comments.