Documentation in Occupational Therapy Practice, 2nd Edition

Goals & Objectives:

Course Goals:

The Occupational Therapy Practice Framework - 4th edition (AOTA, 2020b) provides practitioners with language and terminology that describes the domain and process of occupational therapy provided to clients, which can include persons, groups, or populations. Using the language endorsed by the AOTA strengthens documentation and enables others, outside of occupational therapy practice, to better understand the role of occupational therapy. However, it can be argued that most seasoned practitioners have not had formal training in using the Occupational Therapy Practice Framework language and might have been trained under previous versions such as Uniform Terminology or might not be familiar with the most recent (4th Edition) published by AOTA (2020b). This basic-level course will provide an introduction to this language and foster its use for effective clinical documentation in a variety of occupational therapy practice settings. 

Upon completing this course, occupational therapy practitioners will be able to describe and use effective language and strategies for documentation of occupational therapy and be prepared to explain and use more effective and efficient documentation in many areas of practice. 

Learning Outcomes

Upon the completion of this course, the learner will be able to: 

• Describe effective strategies for occupational therapy documentation 
• Define the occupational therapy practitioner’s ethical and legal responsibility in the context of documentation 
  
• Identify the types of language used in occupational therapy documentation 
  
• Differentiate among the various categories of documentation used in practice 
  
• Identify the documentation used in different occupational therapy practice settings