OT Daily Notes Do's & Don'ts

Hey everyone, Mary Koska here. I am an occupational therapist of 33 years and welcome. I am so glad that you've taken an interest in my handy dandy documentation daily note do's and don'ts. It is just my compilation of things that I like to include in my note and not include in my note. And the reason why is I don't think we should spend any more time on documentation than is absolutely necessary. I think we should be putting that time into having fun with our kids, planning good therapy, having fun in our lives and not taking it home every day. But we want it to be good documentation. We want it to drive quality care and not drive us crazy. Right? So what I'm going to do here is I'm going to go ahead and walk you through the list that you'll get. You'll want to fill out the information so that we can email it to you the PDF. I'm going to share my screen here so I can show you the. I'm going to just walk you through it, what you'll be getting. Right. And so here are the do's. A lot of times people will leave out important demographics in their note. And whether you have an EMR or paper system or a checkoff sheet or whatever, you just want to make sure all this stuff is in it. So you want to make sure you have your session demographics, the date, the start time, definitely the total time in there at a minimum. And you'll want to put the codes that you're billing and even if you are cash pay, a lot of cash pay, parents will want to submit their submit it to insurance anyway, so a lot of them will want to have the code. So just put them in there and what the treatment's for. So if you had say therapeutic activity 97530, you'd want to say what it's for what you're addressing. So you know, maybe you're addressing, you know, maybe you're addressing the fine motor skills, something like that. In the subjective. My thing is I always want to have the golden nugget in there. I want something positive about the progress. The whole note should be communicating progress and your skilled care. So something positive, positive from the parent or if you're in the school, something positive from the teacher. And a lot of times when they're, sometimes it's hard to get something positive like they're overwhelmed by whatever's right in front of them. But like say they just had a big tantrum yesterday and the parents are like, oh man, they just had this huge tantrum and you're thinking, well, it's been a while. You can turn it into a positive by saying, well, how long has it been? They're like, yeah, it's been like three weeks. And so in your note, you can say that they had three, three weeks between tantrums. And that's the positive. So you just want to find something positive to address there whenever possible. Then for the objective part, you definitely want to talk about some measurable change. In two functional goals. It's important to use percentage of assist, number of times. You want to use numbers more than words like mod assist. The main reason for that is it's easier to show measurable change. So if you have 55% assist this week, but 50% the next week, it's pretty clear they're making progress. Instead of mod mod assessment, you need to have a statement in there about that it is medically necessary, at least if you're billing insurance. And then a statement about how they're progressing and how their compliance is. So your note should be so clear. I always say, like the, you should be able to take it to the neighbor who knows nothing about what you're doing. And they could read your note and be very clear that it took a therapist to do this and the kids making progress, not that it looks like, you know, the babysitter could have done this, this with them. So you just have to have enough in there to make it clear that way. And then for your plan, you want to definitely say what's going to be different next session? That's part of your skilled care, is that you're thinking through the next activity or the next session. So I use upgrade and downgrade a lot how I'm going to change the activity to make it fit their ability level. And then you always want to sign your notes and have the date next to the signature, not just at the top. Like, you know, you have your session date there, your note, your signature. I have had notes come back that I had to just put the date next to the name so they want to know when you signed it. All right, and so here are the don'ts. So don't leave off the year. Sometimes people get a little lazy and leave off the year. Don't do that. And I kind of went over this already. Don't leave the date off by the signature. Even if you have the date at the top, you need it in both places. And don't use words that sound like just anybody can do it. So like teaching and coaching and things like that you don't want your note to sound like a teacher could have done it or a babysitter could have done it, our neighbor could have done it. So you want to, you don't want to give too much detail of every exact activity. So for example, I would just say a three step cutting project. I wouldn't say, oh, they made a fish project. And then all the details of the project. You don't need to write a play by play of the whole session to list all your activities. You can have an activity log that similar to like an exercise log. So you can list. So that way you can track and you know which activities were actually done in every session. But you can get yourself into trouble by putting too much detail in the notes because again, it can make it just sound like somebody else could have done it. You know, you're talking about Play doh. And you're talking about bingo or the game Shark Bite. You know, you start talking in detail about those activities, the person reading the note can start to kind of picture this like anybody could have done that. So I'm just more specific about what kind of activity it was. It might be that they followed three step directions during a board game, something like that. Then your activity log helps you keep track of so you know what you did. So it's easier for you to go back and plan and everything. Then you have a record of every single thing you did in the session. It doesn't take a lot of time to write it out. You're just checking things off. Okay, let's see where I was. Yep. Don't leave out the numbers. Always put in numbers so you can do seconds, minutes, repetitions, percentage of assist. Just make sure something's measurable. I always want to have numbers in my note. And sometimes people can get writing notes and not say anything about how they're doing on their goals. You always have to relate it to the goals and you don't want to lack clarity on if they're making progress or not. You want it to be so crystal clear that you actually say they're making progress. And if they're not, you need to say what you'll do differently. So they will. Do you need to downgrade the activity to make it easier for them or is there something going on that's causing them to not make progress? If they've been sick or they're having there's been holidays or the weather, there's been a lot of changes in their life, things like that, you do want to note that. And there's just some things that are just not good to put in your note. You don't want to say like tolerated well or just a lot of repetitive language. You don't want to just say observing, encouraging, supervising none of those things sound like skilled care and you don't want to just say continue clinic care. I know everybody likes to do that don't do that that is a great place to show skilled care so that's just too vague. You want to show a little bit of clinical reasoning like this is what I did in the session and what am I going to do in the next session are they ready for a little level up or do I need to bring it down a little or just anything else that's clinical reasoning put that in your plan and that is pretty much it. So again if you haven't already filled out the info so that your email and such so that we can send you the PDF we will get that to you. Aloha.