Documentation Skills and Occup

An occupational therapist is a trained and licensed health care professional who can make a complete evaluation of the impact of disease on the activities of the patient at home and in work situations. Hobbies and recreational activities are considered when an assessment is made. The most generally accepted definition of occupational therapy is that it is an activity, physical or mental, that aids in a patient's recovery from disease or injury.

The Occupational therapist takes a history from the patient by conducting a thorough interview. Questions are asked about hygiene, eating, dressing, getting in and out of bed, driving, cleaning, working and the patients sex life. A physical examination is conducted extensively concentrating on range of motion. Observations of deformities are noted because they may hinder the performance of the patient. The therapist assesses the need for splints or supports which might benefit the patient and helps design specific assistive devices.

'It is the job of the occupational therapist to innovate plans to overcome the imposed limitations while helping the patient reduce strain and prevent further damage by teaching techniques that conserve energy' (Sasser 75). There are numerous ways to make daily living easier. The most crucial part of therapy is assessing the patient's environment. All the people, cultural conditions and physical objects that are around them, create their environment. The behavior and development of people is a direct result of the interaction between them and their surroundings. A patient's behavior is greatly effected when they are mismatched with their environment. 'A persons environment match is present when the persons level of competence matches the demands of the environment' (Cole 75). Full participation by the patient is required to make it practicable. The importance of occupational therapy is to help the patient use what they have to the fullest. Therapists know that in this particular field there will not be a dramatic improvement, but there will be a better quality of life lived by the patient.

In today's world, it is extremely important to keep accurate records on all aspects of care giving. According to Sladyk, 'Documentation is one of the most important duties an occupational therapist can have aside from treating the patient' (191). As occupational therapy students, it is imperative that we develop these skills and become proficient in the art of technical writing. As technical writers, we will use evaluation reports, daily progress notes, summary reports and discharge plans. Accuracy and attention to detail in the content of these reports is essential in treating and determining the progress of our patients.

Documentation is the means by which we communicate our treatment to other health professionals and third party payers. In most cases, it is necessary to communicate effectively to others, orally and in writing the status of the patient. In addition, documentation is an important aspect of our field because it conveys the status and condition of the patient and our plan and evaluation of said condition to other caregivers. Medical records will be read by the doctors, nurses and in some cases by those submitting payment to the insurance companies. It is important that as occupational therapy students we develop documentation skills early and continue to refine these skills throughout our careers.

In order to implement the guidelines for excellent technical communication, we need to remember the three major reasons to be honest as a communicator. First, we must keep in mind that technical communication is not about using words and pictures to mislead or lie to people. It is about helping people understand how to make wise choices. 'If you lie or mislead, people can be hurt' (Markell 12). Secondly, a patient can worsen in condition if we fail to honestly report our findings. Thirdly, our organization could get into serious legal trouble if we are dishonest. This can lead to lawsuits and malpractice.

A treatment plan is likely to be the first formal piece of documentation an occupational therapy student is likely to write. 'Both the Certified Occupational Therapy Assistant (COTA) and the Occupational Therapist-Registered (OTR) participate in the treatment evaluation and the resulting treatment plan' (Early 94). The OTR is ultimately responsible for the treatment plan. The COTA implements the plan and delivers treatment. After the evaluations have been completed, a comprehensive treatment plan must be documented. This documentation is done by the COTA and later reviewed and checked for accuracy by the OTR.

Each facility has established it's own method for documenting a treatment plan. Some facilities have developed critical pathways that dictate the treatment plan, reducing the paperwork. Generally, a treatment plan includes problems, assets, goals/objectives, treatments, and outcomes/discharge criteria.

Accuracy is paramount in all medical records. Inaccurate writing causes many problems as unclear writing. Therefore, it is key to be accurate as well as neat and understandable. The slightest inaccuracy will confuse the reader. A major inaccuracy, naturally, can be dangerous and expensive. Markell states, 'Accuracy is a question of ethics so our communication must be as objective as possible and free of bias' (13). Documentation that is understandable is legible, ...

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