We are too often ready to blame the type of tools we are required to document from. We should not hold those programs accountable for our lack of quality documentation. We must get back to the essential components of good documentation, focusing on the content, including subjective information, objective data, utilizing tests and measures to enhance outcomes, with an emphasis placed on patient response and functional performance. This must be driven by you, the clinician, and not the forms. Documentation is not an extra step, it is an integral part of the services we provide to our patients. We advocate for our patients by providing quality documentation, which includes documentation of medical necessity, and skilled services, convincing payers of the need for Occupational Therapy services.
This will be an interactive session allowing you the opportunity to enhance your documentation skills.