Even more resources on documentation: Your biggest barrier to productivity

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Even more resources on documentation: Your biggest barrier to productivity

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Last Fall we asked occupational therapy practitioners to tell us their biggest barrier to productivity. Overwhelmingly they told us it was documentation. We provided some documentation resources for practitioners in a September blog post, but we wanted to let you know about a new OT Practice article on documentation.  

Our associate editor of OT Practice, Andrew Waite, interviewed practitioners about their strategies for successful and efficient documentation. Check out the January 23 issue of OT Practice for his article, Record Time: Point of Service Documentation Strategies Help Practitioners Beat the Time Crunch. 

You will find some tips on effective and efficient documentation and learn about electronic documentation. One of my favorite quotes from the article was this:

“[Documentation] shouldn’t be seen as, ‘I’ve treated my patients, now I have got to do this dirty work of documenting.’ It needs to be seen as part of the whole care delivery process for each patient,” says Sharon Kurfuerst, EdD, OTR/L, FAOTA. “So I’m trying to reframe it as, ‘You’re really not done treating Mrs. Smith until her note is written and the chart is closed.’ And if you have that mindset about it, it doesn’t feel like such a big task.” 

A great tip from the article was about how documentation needs to be clinically based and theoretically based—in other words it should show your knowledge as an occupational therapy practitioner. Documentation should not just say that a client is confused or weak, but should identify which muscle is weak and what part of the cognition has changed. 

Read the article online here

Do you do point of service documentation at your clinic? How do you like it? Does it help you be more productive? What other tips and strategies would you share for documentation?

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  • We document and do the billing on I-phones.  It is a part of the therapy session.  It does help to do it with the patient so we have the correct information and at the end of the week it helps with writing the weekly note.  

  • That's interesting Pat. Does your facility provide the iphones?

  • Unfortunately we are using a laptop without wireless. The brick of a computer ends up being a barrier. I agree that an I-phone or a tablet would be more conducive to point of care doc. It's like a notepad or clipboard, not a fence (laptop screen) between us. jl

  • We also use IPhones to document our daily notes, but we do the weelys on paper. It is convenient when you are doing point of service.