University of Tennessee Health Science Center Dept. of Occupational Therapy

1. Introduction to Clinical
Documentation
Stephanie Lancaster, MS, OTR/L, ATP
Spring 2016
OT 425

2. Learning Objectives
• Define the term clinical documentation as it is
used in the field of occupational therapy.
• Identify instrumental persons involved in the
process of clinical documentation.
• Explain why clinical documentation is important
in the practice in OT.
• Name at least 3 examples of specific types of
documentation used by OT practitioners.
• Write a SOAP note based on an observation of a
simulated clinical observation.

3. Clinical
Documentation
What?
Who?
Why?When?
Where?

4. What?
*A record of information collected about the client, including
assessment and intervention techniques used and clinical
observations made by the health care professional.

5. Common Types of Clinical
Documentation
What?
As part of the evaluation phase
• Evaluation or screening report
• Re-evaluation report
During the intervention phase
• Intervention plan
• Service contact log
• Progress report
• Transition plan
In the closing stages of the OT process
• Discharge plan
• Referral report

6. Fundamental Elements of
Clinical Documentation
What?
• Client’s full name
• Date and type of service provided
• Professional terminology and
abbreviations
• OT practitioner’s name, signature,
and professional designation
Correct errands errors in this manner in documentation in paper format.

7. Who?

8. Why?

9. When?

10. Where?

11. Setting-specific Forms
of Clinical Documentation:
The SOAP Note
S - Subjective
O – Objective
A – Assessment
P – Plan
Where?

12. The SOAP Note
Problem: Dependence in wheelchair mobility
S: Client stated that his hands often slip on the metal hand rims when he is
propelling his wheelchair.
O: Friction tape was placed on rims of w/c to improve client’s ability to
grasp and propel w/c. Wheelchair mobility training outside over the
grass and asphalt during functional activity provided. Client
participated for 30 minutes with a 3-minute rest period required at the
mid-point of the session. He experienced no difficulty propelling w/c
during the session, including over uneven surfaces.
A: Friction tape on w/c rims helped improve client’s ability to propel w/c.
Client’s endurance for w/c mobility during functional activities has
improved over the past week.
P: Continue OT intervention targeting training in w/c mobility. Increase
time and distance requirements for w/c mobility and add instruction in
maneuvering w/c in and out of doors and up and down ramps as part
of community mobility and functional activities addressed in OT.

13. Setting-specific Forms of Clinical
Documentation:
The SOAP Note
S
Where?

14. Setting-specific Forms of Clinical
Documentation:
The SOAP Note
S - Subjective
O – Objective
A – Assessment
P – Plan
Where?
O

15. Setting-specific Forms of Clinical
Documentation:
The SOAP Note
S - Subjective
O – Objective
A – Assessment
P – Plan
Where?
A

16. Setting-specific Forms of Clinical
Documentation:
The SOAP Note
S - Subjective
O – Objective
A – Assessment
P – Plan
Where?
P

17. Setting-specific Forms of Clinical
Documentation:
In Early Intervention/Schools
IFSP –
Individualized
Family Service Plan
Where?
IEP –
Individualized
Education Plan

18. Setting-specific Forms of Clinical
Documentation
Where?
The Narrative Note
AROM
EOB
UB
d/t
s/p
d/c
Sample Narrative Note:
Client activity participated in eating during dining
retraining as well as R UE strengthening program.
Client ate 75% of meal using adapted utensils and
required minimal assistance for cutting meat.
Established treatment plan should continue.

19. Setting-specific Forms of Clinical
Documentation
Where?
The Progress Note
Sample Weekly Progress Note:
Client has been treated daily for eating/mealtime retraining and R UE functional
strengthening program. Using adapted utensils, client has eaten 75% of meal with
min. assistance for cutting meat. Previously, client ate 50% of meal and required
mod. assistance for cutting meat.
Goal: Client will eat independently with adapted utensils within one week.

20. Setting-specific Forms of Clinical
Documentation
Where?
The OT Evaluation

21. References
American Occupational Therapy Association. (2009). Guidelines for
Supervision, roles, and responsibilities during the delivery of
occupational therapy services. American Journal of Occupational
Therapy, 63, pp. 797—803.
American Occupational Therapy Association. (2010). Standards of
practice for occupational therapy. American Journal of
Occupational Therapy, 62(Suppl), S106—S111.
Boyt Schell, B. A., Gillen, G., & Scaffa, M. E. (2013). Willard &
Spackman’s occupational therapy (12th ed). Baltimore, MD:
Lippincott Williams & Wilkins.
Clifford O’Brien, J. & Hussey, S. M. (2012). Introduction to
Occupational Therapy (4th ed). St. Louis, MO: Elsevier Mosby, Inc.
Hinojosa, J., Kramer, P., & Crist, P. (2010). Evaluation: Obtaining and
interpreting data (3rd ed.). Bethesda, MD: AOTA Press.