AOTA Resources on Your Biggest Barrier to Productivity: Documentation

We asked 1-Minute Update readers what was their biggest barrier to productivity at work. Overwhelmingly, readers selected documentation (nearly 50% of all votes) as the main barrier to their productivity. As is evident in the results, documentation is met with limited enthusiasm by practitioners. However, documentation is the most important tool of communication, compliance, and reimbursement as well as a way to ensure client safety and care. It also reflects your clinical reasoning and professional judgment. 

AOTA has several resources for members on documentation, including an official document on guidelines for documenting occupational therapy services. The official documentation outlines different types of documentation, the purpose of the reports, and what content should be included. Members can view it here. 

AOTA members can also view this Quarterly article that answers common questions about documentation. The article includes information about how facilities use documentation, the elements of a good medical record, and tips on how to ensure your documentation meets the expectations of the facility, third party payers, and other groups.  

If you are looking for a more in-depth resource, as well as some templates that you can duplicate, you can purchase the book Documenting Occupational Therapy. 

Each practitioner will have to develop a system for him or herself that will allow for efficient but thorough documentation. Some clinicians carry notebooks and take notes while they are with the client, others will go straight to a computer after seeing a client and enter information in a Word document, and now, with more people owning tablet computers such as the iPad (some facilities even provide iPads for their employees), practitioners can quickly type notes regardless if they are near an available computer.

Have you developed a strategy that saves time? Tell us about it in the comments. You can also participate in forum discussions on OT Connections to find out what your colleagues are doing. Remember that even if it feels as if documentation is hindering your productivity, it is your legal record, your source for payment, your rationale for providing occupational therapy services, and it supports and facilitates a client-centered approach. 

Here are a few more documentation-related resources. The July 12, 2010 issue of OT Practice has an article about preparing for electronic documentation (on page 13). A few practice perks in OT Practice also discuss documentation including this one on using forms from other agencies (on page 9) by cutting off the letterhead and this one on whether you need to document (on page 8) for services not being billed.