Different occupational therapy (OT) interventions including physical activities, play activities, developmental activities and adaptive activities can help autistic children perform better in school and home environments. However, occupational therapists should keep their documentation accurate, comprehensive and complete to ensure appropriate and effective therapy services. Such kind of documentation can communicate information regarding the client from the OT perspective, reflect the occupational therapists’ clinical reasoning and professional judgment and client response to OT interventions so that it will be easier to find out opportunities for improvement and make the therapy effective.
According to the American Occupational Therapy Association (AOTA), occupational therapists evaluate autistic children using observation as well as both parent and teacher reports while creating an intervention plan. They will also conduct interviews with parents regarding their child’s relationships and eating, daily living skills and self care. Furthermore, they work with families and teachers as a team to manage the most immediate and important issues. The therapists actually align families, teachers and other service providers in their therapy which help in the academic success of children with autism. In order to make this collaboration successful, therapists should document all the information (for example, communication, visual skills, daily living skills) about the children gathered from these interactions accurately and completely. With this, the therapists can support the parents and help them to be more effective in providing care for their children.
The documentation elements for the intervention process as per the AOTA guidelines are as follows.
- Intervention Plan – The intervention goals, intervention approaches and types of interventions to be used, service delivery details, discharge plan, outcome measures (assessment of occupational performance), details of professionals overseeing the plan and date of plan are documented here.
- Contact Report Note – This section documents the contacts between the patient and the therapist which include the types of interventions used as well as the patient’s responses including telephone contacts, interventions and meeting with others.
- Progress Report/Note – This section includes the summary of the intervention process along with the brief statement of services provided. It also includes the patient’s progress towards the treatment goals, new data gathered, modifications to the treatment plan and statement of need for continuation, discontinuation, or referral.
- Transition Plan – This section documents the formal transition plan (name of current service setting, name of setting to which the patient will be transferred, reason for transition, time frame of transition and outline of activities carried out during the transition plan) along with the patient’s current status and recommendations. This is written when a patient is transferred from one service setting to another within a service delivery system.
Therapists should document their reports according to the payer, facility and federal guidelines. Electronic health records (EHRs) are quite effective in managing all documentation elements for therapists. Even so, the electronic system may sometimes lack completeness and accuracy owing to the templates that limit narration. Moreover, errors may occur inadvertently when copy pasting content hastily to save time. With the help of professional transcriptionists and Discrete Reportable Transcription (DRT) technology, it is possible to populate relevant EHR fields with more complete and accurate information transcribed from the therapists’ dictation.