Documentation Flashcards
Evaluation Report
★ Document the starting point of OT intervention
★ Contain factual data obtained during the evaluation and an interpretation of the evaluation findings
★ Identifies the occupations which are limited or at risk of being limited
★ Include the following:
1. Background information
2. Referral information / physician orders / reason for referral
3. Evaluation procedure / or tests used
4. Occupational profile
5. Occupational analysis
6. Interpreation of the findings & occupational needs of the client
7. A plan, including goals, frequency, duration, & location of intervention
8. Signature & credentials
Treatment Note
★ Often called daily (contact) notes
★ Often utilize SOAP format
★ Completed at the end of or after each intervention session
Intervention / Progress Report
★ Documents client’s progress
★ Shows how the client’s progress has changed since the last intervention session, any functional improvements, adaptive equipment provided, & client or caregiver understanding of instructions
Discharge Report
★ Completed once clients have met long-term & short-term goals or other circumstances where OT services are ending
★ Include the following:
1. Client identification & background information
2, Summary of function status at the initiation of OT services
3. Summary of change in functional status at the close of OT services
4. Results of outcome measures
5. Recommendations for follow-up
6. Signature, credentials, & date
