I’ll admit this isn’t the most exciting topic in OT, but writing good notes is how we show that the service we’re providing is skilled and necessary.
In this article, I’ll discuss how to write better OT notes, interpret Medicare complexity levels, and how to respond to criticism.
I’ll also provide examples and templates for various settings including Acute care, Rehab, Pediatrics, Hand Therapy, and Ergonomics.
This book on writing soap notes is also a great resource.
Why you should write better OT notes
Writing better OT notes starts by asking better questions in your OT session. For most of us, we ask all the right questions and provide skilled services in our session but don’t document it.
When we don’t document what we did, we have no proof that it ever happened.
In most cases, you won’t get audited or be taken to court, but it does happen more frequently that you’d think.
If you do make a mistake and don’t include it in your documentation you run the risk of malpractice and losing your license.
In this next section, I’ll focus on what you can do to make sure that doesn’t happen.
How to write better OT notes
The best way to write better OT notes is to write like you’re presenting them before a jury. You need to clearly and concisely state what you did, the skill you provided, how they responded, their problems and goals, and your recommendations.
Here are some tips on what to include in your SOAP notes.
Subjective
Write down a summarized description of what the person said in response to therapy.
What to include
- Requesting pain meds
- Difficulty with speech
- Pain areas
- Not sleeping
- Feeling depressed
- Abusive relationships at home
- Neglect at home
- Concerns about discharge
- Illogical, confused, or odd speech behaviors (fixated or spontaneous)
- Memory
What to avoid
- Complaints about the food
- Stories unrelated to therapy
- Political opinions
- Anything not related to the patient’s health or safety
Another good tip is to include anyone who was present for the therapy session. For a more complete list of what to avoid, check out Purdue’s SOAP note tips.
Objective
This is the section where you include the history and skilled services/education you provided.
History
Include the patient’s occupational profile/history. Include relevant information for therapy including
- Age and diagnosis
- Past medical history
- Social history
- Steps to enter home
- Stairs in home
- DME or adaptive equipment
- Prior level of function (Level of Independence with ADL/IADL)
The patient’s social history should include who lives with the patient and who is able to care for the patient at discharge.
Record stats
The objective section should include the measurements or treatment activities. It also should include vitals, lab values, or significant values related to therapy.
This may include
- Assist levels for ADLs
- Time spent for activity/exercise
- Repetitions for activity/exercise
- Assessments used and scores/measurements
- Verbal Cue levels
- Respiratory status and settings (Peep, ventilator settings, bipap, airvo)
- How many liters of oxygen
- SPO2 percentage
- EVD values
Education/equipment
You should also include education or patient training. Include equipment issued and caregivers in attendance for training. List the handouts you provided, home exercise programs, and precautions you discussed.
Response to treatment
Don’t just say what you did, but discuss how the patient responded or what you saw.
For example, include how the patient became short of breath or dizzy after transferring to the commode.
Also include what you did to resolve the patient’s response (Returned to bed, blood pressure measurements, etc).
Describe Skilled services
In the objective section you need to include how your services are skilled. In other words, how did your treatment differ from anyone else who may of helped with the same activity.
Instead of saying
- The patient transferred to the toilet with Min assist
Say this
- The patient transferred to the toilet with Min A with verbal cues for balance and safety using the walker.
Assessment
To understand the assessment, most people say to “paint a picture.”
I think it’s better to think of the assessment as to how you would explain the patient’s status to another therapist or clinician.
Do this by explaining how the patient responded to your treatment session.
Explore this in more detail by discussing how this will impact the patient’s ability to complete ADLs and return home.
The more specific, the better.
For example, you might say that the patient’s weakness limits their ability to transfer to the commode making it unsafe for the patient to return home alone.
Make this easy by using a format that works for you. Here’s one example:
Writing the assessment in 3 steps
- The patient’s problems are…(Weakness, SOB, decreased fine motor coordination)
- Limiting the patient’s ability to perform…(list ADLs)
- Requiring…(cont skilled OT, discharge to rehab, equipment, etc)
Using this 3 step format you’re explaining the patient’s problems, limitations with ADLs, and needs for discharge.
In other words, you’re saying why the patient needs OT and what you’re recommending.
Plan
The plan is usually the easiest part, but also one of the most important. In this section, you should include the plan to help the patient meet his/her goals. This might include:
- Frequency/duration
- Discharge recommendations
- DME or adaptive equipment recommendations (Based on facility preference)
- Inventions planned to meet goals
Here are a few phrases you might use in your plan of care:
- Pt will be seen 5x per week for 2 weeks.
- The pt will cont with current plan of care
- The pt will cont to work on ROM exercises in order to progress to strengthening
- The pt will cont to work on ADL transfers in order to go home.
- Recommend d/c to…(SNF, acute rehab, home with home health, outpatient OT)
Writing better goals
If you want to get better at writing better goals, check out my SOAP note template for documenting goals here.
OT goal template for documentation
How to write a Acute care (Hospital) SOAP Note
In acute care it’s important to focus on the daily changes in your documentation. That includes documenting dates of procedures, imaging, vitals, or lab values that may change on a daily basis.
For example, if you’re evaluating a patient who had a stroke you need to include documentation that includes imaging results (MRI, CT), administration times of tPA, PTT, and vitals. You may also need to provide a neurological, visual, and strength assessment.
Discharging is probably the second most important part of your documentation. Make sure every note includes your recommendations for discharge, so the doctor or case manager can easily know by looking at your last note.
Every patient in acute care is different and your documentation should be relevant to each patient’s condition.
Acute Care SOAP Note Template
How to write a Hand therapy Note
Outpatient notes are very different from acute care or rehab. In outpatient, your focus should be on measuring progress, so you can justify your interventions.
Document initial measurements and discuss progress in each note. Every week provide measurements to show how your patient is improving.
Discuss how the patient is responding to home exercises and what attempts you plan to make if the patient isn’t progressing.
Hand Therapy Note Template
How to write an Ergonomics note
Ergonomics is all about pleasing the client. Your note should focus on the client’s impairments and how the workstation is contributing to these impairments.
An ergonomics assessment must be included in your OT documentation. You should also provide recommendations or modifications to remedy the situation.
Ergonomics Note Template
How to write a pediatric note
I’m not a pediatric OT and won’t pretend to be one. If you want more information about pediatric OT notes visit this site.
How to write an SNF or acute rehab note
Acute rehab and SNF documentation should emphasize the ADLs that are impaired and the goals you’re trying to achieve.
Focus mostly on what you did during your time with the patient and how they responded.
Refer to the acute care template for documentation examples.
How to interpret medicare’s requirements for evaluation
With the new changes in Medicare, evals have become more confusing. We now have to document evaluations based on the tiers that include
- Low complexity
- Moderate complexity
- High complexity
It’s important to remember that this new rule for evaluation is not time based. If you spent 15 minutes with a high complexity patient, it’s still considered high complexity.
If you spent 60 minutes with a low complexity patient, it’s still considered low complexity, but you may need bill for other codes to count toward your time (ie Self care, Therex)
The most important thing to consider when billing moderate and high complexity is justifying why you decided on this level.
This table will give you a better understanding on how to choose a complexity level, but for additional information click here.
| CPT level | History Length | Performance Deficits | Clinical Judgment |
|---|---|---|---|
| Low Complexity | Short | 1-3 | Easy |
| Moderate Complexity | Moderate | 3-5 | Moderate |
| High Complexity | Long | 5+ | Complex |
How to respond when others criticize your OT documentation
If anyone has experience in this area, it’s me. I’ve always struggled to write detailed and specific documentation in my SOAP notes, because I’m not a detail oriented person.
I recently wrote an entire post about these challenges.
So what do you do when others respond with positive or negative feedback to your OT note?
#1 Don’t get defensive
I wish I learned this earlier, but the best way to respond is to not react to fear. When we react to fear, we become defensive. This causes us to blame others and we become the victim. When we are the victim we give our power away.
#2 View criticism as a challenge
Instead, respond to feedback by seeing it as a way to learn and grow, even if you don’t agree. There’s always something we can learn from others, and when we respond to feedback as a way to feel challenged, we grow.
#3 Show Appreciation
Try thanking the person for their feedback. This will empower you, and help others see that you can handle stress well.
It also reflects well on your personality, and shows that you can handle challenges in your future.
#4 Focus on the good
Don’t get discouraged. Everyone has a different idea of what good documentation should look like. Don’t dwell on what you’re doing wrong, but focus on what you’re doing right, and how you can do better.
Conclusion
Documentation isn’t easy and every facility has different rules. If you’re struggling with writing better OT notes, ask more questions, focus on more objective measurements, and use the 3 step method to paint your assessment.
I hope this was helpful. To learn more about how you can empower OTs check out this article.
For more exclusive content related to OT, consider subscribing below.
David is the lead editor of OT Focus. He has been practicing as an Occupational Therapist since 2013. He specializes in acute care, hand therapy, and ergonomics.
