Q: How should I complete my documentation when I am providing occupational therapy services in a group setting? 

A: When occupational therapists (OTs) are conducting group interventions there can be variability in the format, structure, and goals of the group. For that reason, there is also variability in OTs’ documentation. OTs should document for all groups that involve occupational therapy service delivery. 

At the minimum, documentation of groups should include:

  • The type of group (one-time education session, weekly reoccurring group);
  • The goals of the group, including the goals of each session if it is a reoccurring group; 
  • Length of the session;
  • Attendance (can be documented on a sheet if the OT is running an education session or in each client’s clinical record if recommendations are provided or occupational therapy goals are addressed);
  • Any adverse events that occurred in the group;
  • The information that was provided to participants (gave handouts regarding “x”, discussed strategies for addressing “x”, provided recommendations for “x”)
  • Any noted individual progress towards goals or any modifications to the goals.

OTs are expected to use their professional judgement and consider the context of their practice in the application of record keeping standards for group documentation. OTs should also consider how to retain any group outlines and handouts that are provided to group participants if they need to refer to them for future reference. Options may be to retain them in a binder format or an electronic format. 

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