Client-Centered Documentation

When observing OTs before school, I was able to meet 5 OTs in settings from hand clinics, orthopedics, to pediatrics. Although in very different settings, each OT made it a point to tell me how much they strongly disliked the documentation process. I believe this is mostly because insurance requires very specific documentation. I noticed that although each setting required computer documentation, almost every OT had their own notepad to take notes on that weren’t just measurements or objective statements that the computer system requested. One hand therapist I observed did not do this. This is understandable because measurements of range of motion and manual muscle testing are very important in this setting. Without notes, the OT even had difficult time remember if the client was trying to return to work, or returning to cooking for her family every Sunday. The other OT that did take personal notes of the client’s life seemed to have a much better connection with her clients.

Now that I have been in school and learned that our job is to be client centered and occupation centered, I realize that it (for me) will be necessary to take my own notes on the client related to their occupational profile, and things that will help me build trust and a therapeutic relationship with the client. In order to be completely sure of the information I believe this will also be beneficial as a backup to double check the information I have put into the computer, for more efficient documentation. Although documentation may be a lengthy, tedious process, it is obviously critical to ensure best treatment and to prove the worth of occupational therapy.