As occupational therapists and healthcare professionals , we know how important thorough documentation is. Not only does it protect us legally, but it allows us to monitor our clients' progress over time and collaborate with other providers.
Among the various notes we write, occupational notes seem to get the least love :( They're often an afterthought we scribble down between sessions rather than an opportunity to showcase our skills.
But what if we approached occupational notes not as a chore, but as a chance to flex our creative muscles? An occupational note doesn't need to be boring! It can be a vivid portrait of the client that brings their experience back to life. Our notes have the power to spark insight and discussion among colleagues. Why not make them as engaging as the clients we work with?
As a practitioner, I've found that writing creatively actually enhances my ability to understand and empathize with clients. It's like mental meditation, replaying our sessions while choosing an evocative yet clinically precise language. As such, with practice, occupational notes can become a mini form of art: concise stories that capture growth in each person who walks through our doors.
In this post, I'll offer some tips I've learned for writing occupational notes with style. I'll also share examples from my notes, edited for confidentiality. My hope is that we can work toward a future where notes become a reflection of our passion for this work rather than an afterthought. With some creativity, even paperwork can be rewarding!
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✅ Individual, Couple, Child, Family therapy types
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Are you finding it more challenging to perform everyday tasks due to a recent wrist injury? Are you a parent who’s concerned about his child's ability to interact with peers due to autism or a disability? Well, we've all had those moments where an injury or change in our abilities makes even the simplest tasks more difficult than they used to be. Getting dressed, cooking a meal, driving to work - the activities we did without thinking can suddenly become major challenges when our bodies aren't working the way they used to. But you don't have to let minor injuries or disabilities sideline you for long. That's where occupational therapy comes in.
As an occupational therapist , nothing is more rewarding than seeing the smile on a client's face when they accomplish a goal they once doubted was possible. Just last week, I was working with an elderly woman who had lost some mobility after a fall. One of her main goals was being able to prepare simple meals again so she wouldn't have to rely on others. After successfully helping her to prepare a grilled cheese sandwich without any assistance, the look of pride and joy was absolutely beautiful. In that moment, I was reminded of why I love this career - helping people find purpose and independence through daily activities is so meaningful.
Occupational therapists’ work involves taking a holistic approach to understand each individual and what truly matters most to them. Rather than just focusing on deficits, we like to ask questions like "What brings you joy in life?" or "What hobbies do you hope to get back to?". This helps us design personalized plans that incorporate meaningful goals. As OTs, we have to get to know our clients as whole human beings to develop interventions tailored to their unique needs, values, and lifestyles.
The diversity of clients and conditions we treat is what keeps this work endlessly fascinating. On any given day, we could be assisting a child with special needs ( autism for example) learn essential self-care routines to thrive in school and social situations, helping an injured athlete slowly progress their rehabilitation exercises to return to sports, or adapting household tasks for someone with arthritis so they can live independently longer. But no matter the presenting problem, our approach follows the same principles - carefully observing each person's abilities, habits, roles and environment to build interventions centered around improving their quality of life.
My friends, as occupational therapists, we know all too well how important clear documentation is to our work. Not only does it protect our licenses, but thorough notes allow for continuity of care as clients transition between settings or providers.
For starters, remember why we're writing - to demonstrate each person's unique needs, goals, and treatment journey over time.
A colleague of mine describes sessions like chapters in a book. I loved her metaphor and plan to borrow it. Instead of drab random notes, we should strive to craft narrative case stories. Weaving in clients' own words helps their voices come through too.
As per regulations, occupational therapists are obligated to record their interactions with clients. To meet this requirement, they commonly employ SOAP notes , which stands for subjective, objective, assessment, and plan. These notes serve as a standardized format for medical documentation, enabling OTs to systematically document their client appointments. By using SOAP notes, OTs enhance their capacity to deliver top-notch treatment in a quantifiable manner.
Let's kick things off with the Subjective section. This one gives us insight straight from the source - our patients themselves! It's where we capture their story in their own words. Starting with the chief complaint, we want to know exactly what brought them in today. Then we dive into their history, learning more about how long they've dealt with this and any factors that make it better or worse. Beyond just medical issues, don't forget about lifestyle habits and home situation too - those impact health as well.
