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Tips for Improving Daily Documentation in Pediatric Settings
Answering YOUR question today - how can I improve my daily documentation?
In the field of OT, documentation is extremely important! Not only is it a way for us, the therapists, to keep track of what we’re doing and why, as well as to show that our clients are making progress, but it’s also important for insurance purposes.
You know the saying “work smarter, not harder”?
You can kind of apply that to writing documentation - write smarter, not longer!
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7 Essentials for Writing SOAP Notes
Sensational Brain CE - OT Documentation Course
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Tips For Improving Daily Documentation In Pediatric Settings
Documentation is a crucial part of being an occupational therapist, but let's face it—it can feel overwhelming, especially when you're just starting out. If you're drowning in notes or struggling to balance providing great therapy and recording it effectively, this guide is for you.
Why Documentation Matters
As occupational therapists and assistants, documentation serves several key purposes:
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Tracking Progress: It's how we show that our clients are improving.
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Insurance Reimbursement: Proper notes are essential for getting sessions covered.
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Legal and Professional Requirements: Documentation protects both the therapist and the client.
However, it doesn’t have to take over your life. Learning a few tricks allows you to streamline your process and return to what you love most—helping kids thrive.
Tips For Smarter Documentation
1. Visualize the Session.
Think of your documentation as a mental replay of your session, focusing on the key moments that stood out. Visualizing what went well, areas for adjustment, and progress toward goals helps you capture the essence of the session efficiently without adding unnecessary details.
2. Keep It Short and Sweet.
You don’t need to record every tiny action; instead, focus on what directly impacts the client’s goals. For example, if a goal involves cutting with scissors, document:
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Assistance level (e.g., "Johnny required moderate assistance").
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Specific outcomes (e.g., "Cut within ¼ inch of the line 50% of the time").
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Relevant observations (e.g., "Used thumbs-up grasp with verbal prompts").
3. Individualize Everything.
Avoid copy-pasting generic phrases and tailor your notes to reflect the unique aspects of each client’s session. Not only does this improve accuracy, but it also helps guide future sessions and makes it easier to show meaningful progress.
4. Use SOAP Notes.
A SOAP (Subjective, Objective, Assessment, Plan) format can help organize your thoughts. Here's a quick breakdown:
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Subjective: Include comments from the client or caregiver, such as "Johnny didn’t sleep well last night."
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Objective: Record measurable data and observations, like "Required 2 verbal cues to stabilize paper while cutting."
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Assessment: Summarize the client’s performance and key takeaways, e.g., "Johnny demonstrated improved hand strength but continued difficulty with bilateral coordination."
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Plan: Outline the next steps, such as "Continue cutting tasks with additional visual aids and provide a home program for practice."
Finding The Right Balance
Documenting During vs. After Sessions
While some clinics may encourage real-time documentation to save time, it’s important not to lose engagement with your client. If you must document during a session, jot down quick notes to expand upon later.
Remember, your primary focus should always be on the child.
Avoiding Burnout
Documentation can be stressful, especially for pediatric therapists who often bring work home. Becoming efficient at note-taking takes practice, but it’s achievable with consistency and confidence.
Set aside dedicated time to document and use templates or prompts to speed up the process.
Practice Makes Perfect
As therapists, we understand that mastery is built through consistent repetition, and documentation is no exception. Just like developing clinical skills, documenting effectively takes practice, and over time, it becomes second nature.
Trust your instincts—focus on what truly matters for your clients, and remember that documentation is about capturing the essence, not perfection. Don’t let the desire to get everything exactly right slow you down.
BORING, BUT NECESSARY LEGAL DISCLAIMERS
While we make every effort to share correct information, we are still learning. We will double check all of our facts but realize that medicine is a constantly changing science and art. One doctor / therapist may have a different way of doing things from another. We are simply presenting our views and opinions on how to address common sensory challenges, health related difficulties and what we have found to be beneficial that will be as evidenced based as possible. By listening to this podcast, you agree not to use this podcast as medical advice to treat any medical condition in either yourself or your children. Consult your child’s pediatrician/ therapist for any medical issues that he or she may be having. This entire disclaimer also applies to any guests or contributors to the podcast. Under no circumstances shall Rachel Harrington, Harkla, Jessica Hill, or any guests or contributors to the podcast, as well as any employees, associates, or affiliates of Harkla, be responsible for damages arising from use of the podcast.
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This podcast should not be used in any legal capacity whatsoever, including but not limited to establishing “standard of care” in a legal sense or as a basis for expert witness testimony. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast.
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