OT Daily Notes Do NOT Need to be Long to be COMPLETE
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.
The Myth of Long OT Notes
In occupational therapy school, we are taught to document everything. This thorough approach is essential for learning, but it often translates into overly detailed documentation in practice. Pediatric OTs, in particular, engage in numerous activities during a session, making it tempting to list every detail. This myth persists because it feels like thorough documentation protects us from scrutiny and ensures we capture every aspect of our work.
The Reality of OT Documentation
Believing that OT notes must be long leads to several negative consequences:
- Increased Work Hours: Spending excessive time on documentation takes away from patient care and personal time.
- Burnout: The additional hours spent on notes contribute to occupational stress and burnout.
- Inefficiency: Long notes do not necessarily mean better notes. They often include redundant information that does not add value.
Benefits of Writing Shorter OT Notes
Writing shorter, complete OT notes has several advantages:
- Save Time: Shorter notes mean more time for direct patient care and personal activities.
- Reduce Burnout: Less time spent on documentation decreases stress and improves work-life balance.
- Improve Efficiency: Templates and concise documentation streamline workflow, allowing for more effective use of time.
How to Write Shorter, Complete OT Notes
- Use Templates: Templates are crucial for efficient documentation. They provide a structure that ensures all necessary information is included without unnecessary details. Customizing templates to fit your practice needs can make documentation quicker and more straightforward. The key is to use your over and over again while personalizing it for the child and session in the quickest way possible.
- Learn what is Required to be in your Notes: Only include essential information in your daily notes. This means focusing on your observations, your clinical reasoning on what is impeding progress and what activities you selected to make gains toward client goals, and client responses and progress. Rather than listing every toy or activity used. Most readers of these notes do not need to know every detail, just the relevant ones.
- Be Concise: Writing concisely involves using bullet points, avoiding redundant phrases, and getting straight to the point. For example, instead of writing, “Today, the patient engaged in various activities such as playing with ‘pop the pig,' ‘building blocks,' and ‘coloring,'” you can write, “Engaged in structured play activities focusing on fine motor skills.”
Overcoming the Fear of Audits
Many OTs fear that shorter notes might lead to audits or denied claims. However, shorter notes can be compliant if they include all necessary information. The key is to ensure your notes clearly document patient progress and outcomes. Testimonials from OTs who have successfully transitioned to shorter documentation can provide reassurance.
From my own experience, transitioning to shorter notes has been a game-changer. Initially, I was hesitant, fearing that I might miss important details. However, by focusing on key information and using templates, I found that my notes were not only complete but also more readable and useful. Many of my colleagues have shared similar success stories, finding that shorter documentation has significantly reduced their workload and stress levels.
OT daily notes do not need to be long to be complete. You must learn what really needs to be included in your notes. Shorter notes can save time, reduce burnout, and improve efficiency without compromising quality.
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