If new information becomes available, progress (or the lack thereof) occurs, additional problems arise, or the simple passage of time means a treatment plan update is needed, note that too, as a prompt to do the update next session. Other guidelines for DAP notes. Feb 17, 2016 Subjective: Symptoms or covert data based on patient's perceptions, sensations, feelings, values, beliefs and attitudes. Objective: Signs that are detectible through senses by an observing, interviewing and examining. What nurses did based on the assessment/evaluation of the.

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OT practitioners spend lots of time on documentation.

Our notes help us track patients’ progress, communicate with other healthcare providers, and defend our rationale for our treatment choices. Documentation is a key factor in our patients’ well-being during their continuum of care.

But, as we all know, charting can take FOREVER—and we might not have the time we need to do it justice.

We are constantly grappling between wanting to write the perfect OT note—one that succinctly says what we did and why we did it—and finishing as quickly as possible.

My vision (and I’ll admit it’s a grand one) is to help you create the type of notes that clearly communicate your assessments and plans, without making you lose your mind in the process.

We’ll start with some basic do’s and don’ts of effective documentation. Then, at the end of the article, you’ll find a sample OT evaluation and some more resources to help you improve your note-writing game.

A quick shout-out: Thank you to The Note Ninjas, Brittany Ferri (an OT clinical reviewer), and Hoangyen Tran (a CHT) for helping me create this resource!

Do’s and Don’ts of writing occupational therapy documentation:
(We’ll take one SOAP note section at a time)

Subjective (S)

DO use the subjective part of the note to open your story

Each note should tell a story about your patient, and your subjective portion should set the stage.

Try to open your note with feedback from the patient about what is and isn’t working about their therapy sessions and home exercise program. For example, you can say any of the following to get your note started:

“Patient states she was excited about ____.”
“Patient reports he is frustrated he still can’t do ____.”
“Patient had a setback this past weekend because ____.”

By sentence one, you’ve already begun to justify why you’re there!

DON’T go overboard with unnecessary details

Let’s admit it: we are storytellers, and we like to add details. But, we must admit we’ve all seen notes with way too much unnecessary information. Here are a few things you can generally leave out of your notes:

“Patient was seated in chair on arrival.”
“Patient let me into her home.”
“Patient requested that nursing clean his room.”

Details are great, because they help preserve the humanity of our patients, but it’s really not necessary to waste your precious time typing out details like these.

Keep in mind that the exception to the above rule is that if a patient is mistrustful of you in any way, adding key details about being let into his or her home might be very relevant!

Channel your inner English major. If a detail does not contribute to the story you are telling—or, in OT terms, contribute to improving a patient’s function—you probably don’t need to include it 🙂

Objective (O)

DO go into detail about your observations and interventions

The objective section of your evaluation and/or SOAP note is often the longest. This is almost certainly the case in an evaluation.

This section should contain objective measurements, observations, and test results. Here are a few examples of what you should include:

Manual muscle tests (MMTs)
Range of motion measurements (AAROM, AROM, PROM, etc.)
Level of independence (CGA, MIN A, etc.)
Functional reporting measures (DASH screen, etc.)
Wound healing details (for post-op patients)
Objective measures from assessments related to the diagnosis

For a comprehensive list of objective measurements that you can include in this section, check out our blog post on OT assessments. We compiled over 100 assessments you can choose from to gather the most helpful data possible.

Assessment (A)

DO show clinical reasoning and expertise

The assessment section of your OT note is what justifies your involvement in this patient’s care.

What you’re doing in this section is synthesizing how the story the patient tells combines with the objective measurements you took (and overall observations you made) during today’s treatment session.

The assessment answers the questions:

How does all of this information fit together?
Where (in your professional opinion) should the patient go from here?
Where does OT fit into the picture for the patient’s plan?

DON’T skimp on the assessment section

The assessment section is your place to shine! All of your education and experience should really drive this one paragraph.

And yet…

We tend to just write: “Patient tolerated therapy well.” Or we copy and paste a generic sentence like this: “Patient continues to require verbal cueing and will benefit from continued therapy.”

Lack of pizazz aside, that’s not enough to represent all that education you have, nor all that high-level thinking you do during your treatments.

Consider something like:

“Patient’s reported improvements in tolerance to toileting activities demonstrate effectiveness of energy conservation techniques she has learned during OT sessions. Improved range of motion and stability of her right arm confirms that her use of shoulder home exercise plan is improving her ability to use her right upper extremity to gain independence with self care.”

Plan (P)

DON’T get lazy

I once went to a CEU course on note-writing, and the course was geared toward PTs.

It felt to me like most of the hour was spent talking about how important it is to make goals functional. But we OTs already know this; function is our bread and butter.

So, why do many OTs insist on writing things like: “Continue plan of care as tolerated”??

Not only do utilization reviewers hate that type of generic language, it robs us of the ability to demonstrate our clinical reasoning and treatment rationale!

DO show proper strategic planning of patients’ care

This section isn’t rocket science. You don’t have to write a novel. But you do need to show that you’re thinking ahead and considering how your patients’ care plans will change as they progress through treatment.

Consider something like this:

“Continue working with patient on toileting, while gradually decreasing verbal and tactile cues, which will enable patient to become more confident and independent. Add stability exercises to home exercise program to stabilize patient’s right upper extremity in the new range. Decrease OT frequency from 3x/week to 2x/week as tolerated.”

Short, sweet, and meaningful.

General DO’s and DON’TS for documentation

Your patient is the hero—and you are the guide. In every good story, there’s a hero and a guide. The patient is Luke Skywalker, and you are Yoda.

I think as therapists, we tend to document only one part of the story.

For example, we focus on the hero’s role: “Patient did such and such.”

Or we focus on what we, the guide, bring with our skilled interventions: “Therapist downgraded, corrected, provided verbal cues.”

But, a really good note—dare I say, a perfect note—shows how the two interact.

If your patient tells you in the subjective section that they are not progressing as quickly as they would like, what did you do, as the therapist, to upgrade their intervention? Your notes should make it apparent that you are working t

Do’s and Don’ts of writing occupational therapy documentation: (We’ll take one SOAP note section at a time)

Darp Notes Examples