Introduction to Documentation (OT)

OTs and OTAs can be referred to as occupational therapy practitioners or therapists

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When skilled therapy is no longer needed, the OTA has responsibility for writing the discharge report if they treated the client for the final session

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The Acronym SOAP stands for subjective, objective, appraisal, plan

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An alternate form of a SOAP note could be a narrative note

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To differential occupational therapy from other disciplines, OTs and OTAs should focus their documentation the client's ability to engage in occupation

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The OT cannot change an established occupational therapy intervention plan once treatment has been initiated

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OT notes tend to be very consistent in content and style across different types of practice settings

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A transition note might be written when a client is transferring from special education to vocational services with the same system of service delivery

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OTAs document performance skills such as reflexes and range of motion

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• True

ADL (occupations) include activities to improve or manage one's health, such as wearing an orthotic device, taking prescribed medications, or using a glucometer

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• False