Online Continuing Education Courses

Documentation of Occupational Therapy Services

• Identify five purposes of documentation
• Describe the basic technical points that should be adhered to when writing in the medical record
• Explain why only approved abbreviations should be used in occupational therapy documentation
• Describe the acceptable method of correcting an error in the medical record
• Explain why occupational therapy documentation should reflect the terminology outlined in the Occupational Therapy Practice Framework
• Describe the components of a well-written progress note
• Identify the different places where documentation is required
• Briefly summarize the content of the initial evaluation
• Define assessments as they apply to the occupational therapy process
• Describe the purpose of the intervention plan
• Explain why establishment of goals should be a collaborative effort between the client and the therapist