Documentation in Occupational Therapy Practice, 2nd Edition

Course Description: At one time or another during their education or practice experience, most occupational therapy practitioners hear the statement, “If it’s not documented, it didn’t happen.” In most practice settings, occupational therapy practitioners are expected to complete some type of documentation required by their place of employment, practice setting, and/or licensure requirements. Proper documentation provides suitable records of client contact, evaluation, and interventions that offer client information from an occupational therapy perspective, articulate the rationale for occupational therapy services, and provide a chronological record of the client’s status (American Occupational Therapy Association [AOTA], 2018). Additionally, these records are often required as part of payment for service (reimbursement) and provide a legal record of services rendered.  The 2018 Accreditation Council for Occupational Therapy Education (ACOTE®) Standards stipulate curriculum requirements for occupational therapy education programs that include documentation as a required function of occupational therapy faculty members (A.2.3, A.2.15, A.4.6.) and a technical skill set developed via the curriculum for future occupational therapy practice (B.4.15, B.4.29; ACOTE, 2018). Even in academia as a practice setting, faculty members must use various forms of documentation to support and substantiate their students’ academic records and professional development.