Introduction to Documentation

Who are the primary audiences for occupational therapy documentation?

• Only the client

• Only the intervention team

• Multiple audiences including caregivers and third-party payers

• Only facility quality management personnel

What is a key reason for accurate documentation in occupational therapy?

• To reduce paperwork

• To ensure compliance with regulations

• To impress clients

• To avoid legal issues and protect practitioners

What does the phrase 'if it is not documented, it didn’t happen' imply?

• Documentation is optional

• Documentation is crucial for accountability

• Documentation is only needed for legal cases

• Documentation can be done later

When is it best to document occupational therapy sessions?

• During lunch breaks only

• At the end of the week

• As close to the time of service as possible

• Only when the client requests it

What should be included in the documentation of an OT session?

• Client's reaction and future service plans

• Just the time spent with the client

• Only the activities performed

• The therapist's personal feelings

Why is it important to choose words carefully in documentation?

• To fill space in the document

• To impress third-party payers

• To avoid misinterpretation by various audiences

• To make it sound more professional

What is a common practice for OTs who cannot document immediately?

• They document everything at the end of the month

• They ask clients to remember details

• They write notes on small pieces of paper

• They ignore documentation

What type of documentation is considered stronger in a court of law?

• Documentation written at the time of the event

• Documentation written from memory

• Documentation written by a substitute OT

• Documentation that is vague

In which settings is occupational therapy documentation typically found?

• Only in clinical settings

• Only in educational settings

• In both clinical and educational settings

• Only in private practice

What is the purpose of documenting the client's reaction to interventions?

• To satisfy regulatory bodies

• To make the documentation longer

• To provide evidence of effectiveness

• To fill out paperwork