Take Note!

Clinical documentation is necessary in all health-related professions! It is extremely important for our profession of occupational therapy. Documentation provides a justification for OT service and an accurate record. It gives an insight of what we done, where they are, and a plan. This records allows common communication with other practitioners who might also be working with the same client. In our profession, it is common the use the SOAP method when writing documents on a client. The SOAP has four main parts: subjective, objective, assessment/ analysis, and plan. This plan makes sure we cover everything that is needed for documentation. If you don’t document, it didn’t happen!