1. Tips for Writing a Better “O”
Workbook chapter 8

2. Focus on Function Connect your treatments back to occupations
Ex: Student engaged in hand strengthening and in-hand manipulation activities.

3. Focus on Function Connect your treatments back to occupations
Ex: Student engaged in hand strengthening and in-hand manipulation activities.
Better: Student engaged in hand strengthening and in-hand manipulation activities in order to improve ability to participate in age-appropriate handwriting skills in the classroom.
Example of a school-based goal

4. Focus on Function
Ex: Client participated in training for functional mobility and energy conservation.
What’s a better way to write this and relate it back to occupations?

5. Focus on Function
Ex: Client participated in training for functional mobility and energy conservation.
Better: Client participated in training for functional mobility and energy conservation in order to regain her ability to safely engage in ADLs independently in her home environment.

6. Write from client’s point of view
Avoid mentioning yourself in your note
Focus on the client in your word choice / sentence structure
Ex: OTA instructed family in child’s HEP

7. Write from client’s point of view
Avoid mentioning yourself in your note
Focus on the client in your word choice / sentence structure
Ex: OTA instructed family in child’s HEP
Better: Family was instructed in child’s HEP and demonstrated ability to carryover activities in the home environment.

8. Write from client’s point of view
Ex: OTA assisted client with mod A to transfer from w/c to raised toilet seat.
What’s a better way to word this? (more client-centered?)

9. Write from client’s point of view
Ex: OTA assisted client with mod A to transfer from w/c to raised toilet seat.
Better: Client able to transfer from w/c to raised toilet seat with mod A.

10. De-emphasize tx media
Focus on performance skills, not the actual activity/media itself
Always relate it back to skills and function
Remember to use skilled, professional language

11. De-emphasize tx media
Ex: Client worked on theraputty activities.

12. De-emphasize tx media Ex: Client worked on theraputty activities.
Better: Client instructed in hand strengthening theraputty activities to improve functional hand strength for grasping during participation in ADL tasks.

13. De-emphasize tx media
Ex: Child participated in 5 minutes of finger-painting.

14. De-emphasize tx media
Ex: Child participated in 5 minutes of finger-painting.
Better: Child tolerated 5 minutes of tactile input with fingerpaint on hands, in order to decrease tactile defensiveness and improve ability to participate in age-appropriate tactile play without aversion.

15. Avoid judgment/personal bias
Clients can have difficult behaviors
Difference between professional judgment and personal judgment
Ex: Client was uncooperative and moody, he did not want to try to use his R hand during dressing tasks and would not cooperate with OTA’s instruction for compensatory dressing techniques.
What’s a better way to document this?

16. Avoid judgment/personal bias
Clients can have difficult behaviors
Difference between professional judgment and personal judgment
Ex: Client was uncooperative and moody, he did not want to try to use his R hand during dressing tasks and would not cooperate with OTA’s instruction for compensatory dressing techniques.
Better: Client demonstrated emotional lability and resistance to instruction. Client required max encouragement and HOH assist to participate in skilled instruction for compensatory dressing techniques to use his affected R UE in dressing tasks.

17. Be specific about assist levels
Exactly what part of the skill/activity did they need help with?
What type and amount of assistance was needed?

18. Be specific about assist levels
Ex: Child needed assistance to remember 3-steps and complete obstacle course.
What kind of assistance? How much? For what parts of the activity?

19. Be specific about assist levels
Ex: Child needed assistance to remember 3-steps and complete obstacle course.
Better: Child required a picture schedule and 1 verbal cue to sequence a 3-step obstacle course, with close supervision for safety on suspended equipment.

20. Be specific about assist levels
Ex: Client needed assistance to transfer from w/c to toilet.
What kind of assistance? How much? For what parts of the activity?

21. Be specific about assist levels
Ex: Client needed assistance to transfer from w/c to toilet.
Better: Client required min A to transfer from w/c to raised toilet seat with 2 verbal cues for safety and hand-placement on grab bars.

22. Specify the level of complexity of task
Specify the grading of the task, number of steps involved
Ex: dressing tasks
Ex: meal preparation
Ex: home management tasks
Dressing: velcro easier than laces. Elastic pants easier than jeans with zipper and button, etc.
Meal preparation: instant soup easier than cooking recipe from scratch, etc.
Home mx: loading a dishwasher is fewer steps than washing dishes by hand, etc.

23. Specify devices used
Specify any adaptive equipment or ambulation device used
Relate it back to FUNCTION and occupation

24. Transfers Refer to table 8-1 on page 75

25. PAMs
Using a PAM is not considered skilled OT unless you document how it prepares/enables the client to perform specific functional tasks.
Again, always relate it back to FUNCTION and occupation.
Examples of PAMs: ultrasound, ice/heat, e-stim, etc.
Always requires service competency, special training.

26. PAMs Specify where modality is placed on the body
Specify time, temperature, intensity, and any special positioning
Specify the functional purpose (pain relief, ROM, ADLs, etc.)
Describe tolerance to tx and any progress
Refer to table 8-3 on page 78
Examples of PAMs: ultrasound, ice/heat, e-stim, etc.