The Disconnect in OT Documentation Practices: Perhaps We Should Think

Hao, an occupational therapist, discusses the importance and complexities of documentation in the field. He highlights issues such as clarity, digital versus paper-based methods, and the audit processes used to ensure compliance with standards. Hao identifies four key types of notes: initial contact/assessment, problem statement, contact notes, and discharge notes, emphasizing their importance in a patient-centered, interdisciplinary approach. He also addresses the challenges of outdated practices in the digital age and advocates for standardizing certain documentation practices to enhance efficiency and reliability across the profession.