Documentation

Timely and accurate documentation is necessary whenever occupational therapy services are provided, regardless of payer source. The Client's record must be signed with the provider's name, professional designation, and license number. (1) The occupational therapist's primary role in documentation is to ensure that documentation is completed timely, following formats and standards established by the practice setting, agencies, external accreditation programs, state and federal law, and other regulators and payers. The occupational therapist's primary role is to document the following, with input from the occupational therapy assistant, as applicable: (a) Screenings; (b) Evaluations; (c) Initial goals and any modifications in goals, as needed; (d) Initial Intervention Plans and any modifications; (e) Patient progress notes; (f) Formal reviews of the initial Intervention Plan (or reevaluations); and (g) Discharge Evaluations or summaries. (2) The occupational therapy assistant's primary role is to document the following: (a) Objective data from Assessments with established Service Competency; and Patient progress notes as directed by the Occupational Therapist. (3) The Occupational Therapy Aide's primary role is to document objective information, such as number of repetitions performed, etc., on documents such as logs and flow sheets.