Question: How often should an occupational therapist be documenting in the clinical record?

Answer: It depends. Using clinical judgement is important in determining the frequency of your documentation. How often an occupational therapist documents may depend on client factors, situational circumstances, identified risks, as well as practice setting or employer expectations.  Generally, an entry should be made in the clinical record when:

  • a professional encounter has occurred with the client unless it is captured through an appointment book, attendance log or using a workload measurement system 
  • there is significant change in the client’s status, 
  • when the client is assessed or reassessed,
  • when there are changes in goals or the occupational therapy service, 
  • there are changes to consent, 
  • when relevant information that has clinical value is received or is to be communicated to the health care team
  • there is a transfer of care

Occupational therapists should ensure their documentation is clear with sufficient detail to allow another health care provider, client/SDM to understand what occurred during the course of the professional encounter with the OT.  This may also include the need to document when there is “no change” to avoid gaps in records that could raise questions from others when the record is reviewed, or the client is transferred.

Resources

Our Practice team is here to help.

If you have any questions, contact the Practice Resource Service at 416.214.1177 ext. 240 or email practice@coto.org


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