Importance of Proper Documentation & Goal Setting as an OT Practioner (OT 425)

In many settings and situations we encounter today throughout our daily lives, it is so important to take note of the things we do, say, think and how we act.  I believe this is how we continue to grow and develop as a society and continue to make positive changes in the world we live in. “Taking note” can be thought of in many different ways such as just recognizing the changes within our lives or it can mean physically writing it down.  For many professions having proper and official documentation is required in order to properly complete one’s job to the best of their ability.  Documentation plays a huge role in the medical field in general but today I’m going to talk about why it is important in occupational therapy.

Occupational therapy is a discipline in which a client will be seen by an OT practitioner to help them with a specific problem or challenge they are facing.  The OT practitioner should be able to look at the client in a holistic manner and learn more about what barriers they are experiencing and what their overall goal is. As soon as the OT practitioner beings speaking to the client, he or she will need to begin taking notes about anything and everything that might be relevant to this clients diagnosis.  It is important for the OT practitioner to not only document what the client or caregiver says but also what they observe from the conversations.

Having proper documentation not only allows the practitioner to have an accurate records but it helps to provide justification for services and showcases the true job of an OT practitioner.  In my opinion, the most important part of documentation for an OT practitioner is the long and short terms goals that they set with the client.  Having goals allows the client and the practitioner to know exactly what they are working towards and what type or progress they should see throughout their sessions.  It’s important to always let the client know that the goals are flexible and fluid and can change depending on how their treatment plan goes. There are many different methods of writing goals but its necessary it including the following components: relevancy, duration, understandable, measurable, achievable and believable.  Goals can help motivate and drive the client and practitioner to keep working at their best levels and to see how far they’ve come. To me, that is what OT is all about - guiding and helping someone do their best and living the most fullfilling and satisfacting life that they can.