Documentation in OT

In this blog post I will be discussing a few types of clinical documentation used in healthcare professions but specifically in occupational therapy.

The most common documentation style seen is the SOAP note. SOAP is an acronym for Subjective, Objective, Assessment, and Plan.  In the subjective piece of documentation the therapist will put what was said by the client or their caretaker.  In the objective piece the therapist will write what they observe the client do.  In the assessment portion the therapist will take what they collected in the subjective and objective parts and interpret it. In the plan portion, the therapist makes a plan or writes goals for the future treatment of the client.

In early intervention and schools, a therapist might often document using an Individualized Family Service Plan (IFSP) or an Individual Education Plan (IEP).  The IFSP is begun when the child is 3 years of age and it also includes the parents in the plan.  An IEP is used in special education programs in schools and can lead into getting a special education diploma.

A couple of others worth mentioning are narrative notes and progress notes.  A narrative note is written in story type form and tells about treatment given, what the therapist observes, and what the client achieves in the session.  A narrative note can be in SOAP note form but it does not have to be. A progress note tells what has been accomplished over a set amount of time.  It is more popular than the narrative note.

These are just a few examples of documentation seen in occupational therapy.  It is good to know that there are many variations of documentation as you never know what your professional setting will require.

The OT Process Explained

The OT process includes the following steps: the evaluation process, the intervention process, and the outcome process.

Included in the evaluation process is the referral, screening, and occupational profile.  Referral for OT services most often comes from a physician, which is required for reimbursement and liability.  OT screening includes an interview and observation of the client by the therapist. The occupational profile can be beneficial for collecting information about the client's roles, daily activities, and activities of interest.  The evaluation process is critical for collecting all needed information about the client and for forming a client-therapist relationship.

The intervention process has three basic steps: plan, implement, and monitor.  The therapist should try to select purposeful activities that will be meaningful to the client.  The collaboration of the client and therapist will result in successful interventions.  Providing a "just right challenge" by grading the activity up or down to fit the needs of the client is important for best intervention treatments.  Occupation in the step often used as a means of intervention in order to meet the end goals.  As intervention progresses, the therapist should reevaluate the progress and selected interventions to adjust goals and treatment.

Last in the OT process is the outcomes.  This is the part of the process where the therapist must decide to continue or discontinue services.  If the client has not met the desired goals or has new goals to work on, the OT process may repeat itself. Discharge planning includes all people involved including the therapist, client, family, and other disciplinary teams.  All variables of the clients well-being must be considered in discharge planning.  In discharging a client, a discontinuation summary is written.  Documentation in this step and throughout the whole process is crucial for best care and for legal and ethical reasons as well.

That is a simplified short version of the OT process.  Stay tuned for more OT knowledge!

Joni Eareckson Tada

In class today, I learned about an inspirational woman named Joni Eareckson Tada who suffers from a spinal cord injury.  At 17, she dove into shallow water and sustained a C4/C5 spinal injury.  She went from being extremely active to being a quadriplegic.  Instead of letting this slow her down, she has adapted and has done incredible things.  She has written over 50 books, painted beautiful pictures, and is a wonderful singer.  Not only was her story inspirational but seeing how OT fit into her story was beautiful.  After her injury and hospital stay, she was placed in a rehabilitation facility and her OT encouraged her to use a mouth stick and begin to paint.  Providing this leisure activity for Joni really made a difference in her life.  To see this exceptional lady adapt and do so well is encouraging to me as I encounter others with a similar injury.  Perhaps I can share this story with future clients and inspire them to be great in my role as an OT.

Parkinson's, depression and the switch that might turn them off

Parkinson's, depression and the switch that might turn them off

As a lover of TED talks, I was drawn to do my first neuro note on a TED talk.  This TED talk caught my attention because the title indicated that it was about Parkinson's and depression, both conditions that affect people I know and love.

This TED talk was made by a neurosurgeon, Dr. Andres Lozano.  In this talk, he spoke about a new treatment technique called deep brain stimulation.  Deep brain stimulation allows circuits in the brain to be "dialed up and down" on hyperactive or hypoactive areas in the brain.  This procedure requires the surgeon to make a dime sized hole in the skull and the placement of an electrode into the desired area of the brain.  The electrodes can adjust the circuits in the brain to help with movement, mood, and cognition disorders.  Dr. Lozano then provided a few examples of deep brain stimulation and its effects in various conditions.  He showed how the deep brain stimulation stopped the shaking of a lady with Parkinson's, reversed the effects of dystonia, and improved the mood dysfunction of depression.

Seeing the ways this new technology can drastically improve and even save the lives of many was inspiring and uplifting to see.  I enjoyed seeing another way that these neurological conditions can be improved.  As an OT, I am excited to see advances in medicine that can improve quality of life and give an individual a full life.  I highly encourage you to watch the video for yourself (link below) and see what a difference this technology can make in the prognosis of patients with these disorders.


Lozano, A. (2013, January). Parkinson's, depression and the switch that might turn them off [Video file]. TED Talk, Retrieved from https://www.ted.com/talks/andres_lozano_parkinson_s_depression_and_the_switch_that_might_turn_them_off#t-918696

What is health literacy and why is it important?

In my foundations class, we discussed health promotion and literacy and this video that we viewed in class struck me. https://www.youtube.com/watch?v=ubPkdpGHWAQ

Health literacy is "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (https://health.gov/communication/literacy/quickguide/factsbasic.htm)."  Poor health literacy is prevalent in all healthcare settings, yet, it is often overlooked.  In this video, you can see that not everyone speaks "healthcare lingo" and many could not read or could not understand what they read.  The people in the video are great examples of average people being embarrassed about their inability to read or understand.  Also, not knowing what to ask can keep people from speaking up to ask the practitioner about what they do not understand. We need to do our best to keep our language simple when discussing treatment and ask clients follow-up questions that prove understanding.  As, therapists, we need to be aware that a client may not understand their diagnosis or the reasons for the treatment plan so we can help in health literacy by being willing to talk about their healthcare and answer any questions. Health literacy can be improved by practitioners being aware that there are gaps in understanding, looking for signs in our clients of lack of understanding, and consciously trying to promote health literacy with those we serve.

Below is the link to a great YouTube video that describes health literacy and gives ways that we as health care professionals can improve health literacy and further, improve care for our patients.
https://www.youtube.com/watch?v=_8w9kdcRgsI&feature=youtu.be

Universal Design

Universal design is an idea that encourages architecture, products, and equipment to be designed in a way that is accessible to the largest majority of people.  This is not making a separate item or way that people with disabilities use but instead a design that is user friendly for all.  Take for example these steps in the picture below.  The ramp for those using a wheelchair is not a block down the street or even nonexistent but instead it is in a accessible place within the stairs that everyone can use. Designs such as this one leaves less room for discrimination and helps everyone have an equal opportunity to participate. Living with a disability should not come with the added strain of not being able to use certain products or participate in activities because of inconvenient architecture.  Since learning about universal design, I have been on the lookout for universal design in the world around me.  I hope you will find yourself looking too.  Maybe if we can get people to begin to notice the ways that products discriminate, the world can begin to make steps toward making our world user friendly for all.

Being more than a healthcare professional

One of my professor's in occupational therapy school shared with us a heartbreaking story about her father via a blog she had written.  This was the story of a healthy, active man that acquired a rare form of brain cancer.  The blog post told of his journey/battle with this cancer and the impact that his illness had on his family, including my professor.  I was touched by this man's life while also appalled at some of the service he and his family received from so-called "health professionals".  As a future occupational therapist, I would like to believe that all healthcare providers try their best to provide the best care possible to their patients and really go above and beyond to make their patients comfortable.  Unfortunately, it seemed that the majority of the healthcare providers in his story had become complacent and satisfied with doing the minimum amount.  I hope I can remember the story my professor shared with us for the entirety of my career, at all times, good days and bad days, with frustrating and great patients.  I want to be a healthcare professional that goes above and beyond for my patients and their families.  I want to be a therapist that takes the time to care for each patient with my whole heart.  I want to be an OT that does the little extra to make a huge difference in patient's care.  I hope I become a better professional than these I read about in this story and I hope to inspire others to do more too.

Disabling a person by labeling them "disabled"

Aimee Mullins gave a TED MED talk called "The opportunity of adversity" that brings up some interesting thoughts.  Aimee Mullins is a double leg amputee. In this talk, she is speaking about being disabled and she mentions recently looking up the word disabled in a thesaurus.  The results included negative words such as crippled, weak, and hopeless.  She says that she would have been crushed to see these definitions as a child.  She shares this thought: "In our desire to protect those we care about by giving them the cold, hard truth about their medical prognosis, or, indeed, a prognosis on the expected quality of their life, we have to make sure that we don't put the first brick in a wall that will actually disable someone."  It is so important as therapists, parents, and care givers, that we do not limit others by defining the things we believe they can or cannot do.  We must challenge them to be better through positive encouragement.  She expressed that her pediatrician positively challenged her as a child when she was struggling to enjoy physical therapy and she believes it made all the difference.  Let us be careful not place labels and boxes around the disabled in our lives for fear that we only disable them more.