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Documentation of occupational therapy services is required whenever professional services are provided to a client.1 Occupational therapy practitioners2 identify the types of documentation required and record all necessary components of services provided within their scope of practice. This document, based on the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; American Occupational Therapy Association [AOTA], 2014b), describes the purpose, types, and content of professional documentation used in occupational therapy.
AOTA's (2015c) Standards of Practice for Occupational Therapy states that an occupational therapy practitioner documents the occupational therapy services and "abides by the time frames, formats, and standards established by practice settings, federal and state laws, other regulatory and payer requirements, external accreditation programs, and AOTA documents" (p. 4). These requirements apply to both electronic and written forms of documentation though may vary considerably by practice setting and facility. AOTA's (2015a) Occupational Therapy Code of Ethics states that occupational therapy practitioners "shall promote fairness and objectivity in the provision of occupational therapy services" (p. 5) and "shall provide comprehensive, accurate, and objective information when representing the profession" (p. 6).
Occupational therapy documentation reflects the nature of services provided, shows the clinical reasoning of the occupational therapy practitioner, and provides enough information to ensure that services are delivered in a safe and effective manner. Documentation describes the depth and breadth of services provided to meet the complexity of client needs and responses to occupational therapy services at the individual, group (community), or population levels.
The purpose of documentation is to
* Communicate information about the client's occupational history and experiences, interests, values, and needs;
* Articulate the rationale for provision of occupational therapy services and the relationship of those services to client outcomes;
* Provide a clear chronological record of client status, the nature of occupational therapy services provided, client response to occupational therapy intervention, and client outcomes; and
* Provide an accurate justification for skilled occupational therapy service necessity and reimbursement.
Types of Documentation
Documentation of occupational therapy service is maintained in a professional and legal fashion (i.e., complete, concise, accurate, timely, legible, clear, grammatically correct, objective) for each client served. Table 1 outlines common types of documentation used by occupational therapy practitioners.
Documentation types may be identified differently or combined and reorganized to meet...