Most OTs think that occupational therapy documentation daily notes need to be LONG to be COMPLETE but that might be the biggest myth in healthcare.
I understand why. We learned in school you must document everything you did during a session in your daily notes. And many times pediatric occupational therapists do A LOT during each session. Especially when occupational therapists work with children. So it’s easy to believe.
But if that were true, then everyone who writes shorter notes would be audited and their sessions would not be getting paid. And we all know this is not the case. In fact, if you keep holding this belief, you will burn out from spending so much time outside of work hours documenting!
But do you know how to actually write shorter, yet complete notes without the fear of being audited?
If you're not thinking about TEMPLATES when you hear the word documentation you are probably spending too much time documenting.
I think of documentation as just a quick way to share what you did in that session to help a child achieve their goals.
Once upon a time, I would have immediately thought of DREAD, but times have changed.
First, Stop Thinking you have to Document EVERYTHING.
Second, We Do Not need to List all the Toys we use in Sessions
I am just not convinced others are reading these notes for details.
We need to remember that most people will not know what “pop the pig” even is.
Much less why an OT would use it as an activity. So why are we listing all the toys we used in a session?
So let me ask: Do you really want to keep wasting your time writing unnecessarily long daily notes? Or do you want to learn how to write short + quick documentation that includes everything you need?
What if you could feel confident knowing you have documented what you NEED to in a note, but not spent more than 5 minutes writing that note?
Occupational Therapy Documentation at its Simplest is BEST.
Templates free up mental space when you are writing your notes. Who can use more mental space?
What is the one thing you say over and over in your notes? How can you make it simpler and be used as a template?
- Follow a template
- Show the value of OT in daily notes
- Stop treating daily notes like a report card!
Do you need help writing SOAP notes?
Not sure what you should be in your daily SOAP notes? Want an easy, reproducible format to use for your notes? Check out the template!
Designed for students, fieldwork students, and new therapists.
3 Easy Other Ways to Decrease OT Session Planning and Documentation Time
Step One: Focus on the WHY of the session activities BEFORE searching the internet for treatment activities
Step Two: Focus on what NEEDS to be included in daily notes instead of including EVERYTHING in a session
Step Three: Write FUNCTIONAL goals using the same format for all your clients
Are you billing the current amount of time for your sessions? Do you follow the 8-minute rule?