Last Thursday, we learned about OT documentation. The goal of documentation is to provide enough information to ensure that our OT services are administered in the most effective way. It is important to be nonjudgmental when documenting and to think about the family and other individuals who could be reading it.
Goal writing is also a big piece of documentation. It is important to begin with the end in mind. There are short term goals and long term goals. Short term goals describe what the client will do in around 30 days to 2 weeks. These goals change during intervention and typically will relate to skill building. Short term goals can be thought of as the little goals that lead to occupational performance. On the other hand, long term goals are the goals that identify what the client will do by the time of discharge from OT. These goals usually relate to occupation and function.
As an OT, documentation is a big part of occupational therapy. It will be necessary for the goals to be written using verbs that are active instead of passive. Goals must also be able to be measured and have a time limit. When I took an undergrad class called Therapeutic Recreation in Public Schools, we had to write IEPs and progress reports for the students we worked with. With these reports, goals, and objectives, we had to use active verbs as well. Having some experience will hopefully help me in the future with using these verbs and documenting.
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