![]() “Patient was seated in chair on arrival.”.Here are a few things you can generally leave out of your notes: But, we’ve all seen notes with way too much unnecessary information. Let’s admit it: we are storytellers, and we like to add details. DON’T go overboard with unnecessary details In sentence one, you’ve already begun to justify why you’re there! If you need some good questions to draw out this kind of feedback from patients, check out Good Questions for OTs to Ask. “Patient had a setback this past weekend because _.”.“Patient reports he is frustrated he still can’t do _.”.“Patient states she was excited about _.”.For example, you can say any of the following to get your note started: Try to open your note with feedback from the patient on what is and isn’t working about their therapy sessions and home exercise program. Subjective (S) DO use the subjective part of the note to open your storyĮach note should tell a story about your patient, with the subjective portion setting the stage. We know documentation varies widely from setting to setting, so we are using the universal SOAP (Subjective, Objective, Assessment, Plan) note structure to break down our advice.Įven if you don’t use this exact structure in your notes, your documentation probably has all of these dimensions. DO’s and DON’Ts of Writing Occupational Therapy Documentation
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