OT 425 Clinical Observation and Documentation

Clinical observation is very dependent on our own perspective; we may make different observations and notice different things depending on our perspective. Structured observation is a pre-determined activity, such as simulated or real cooking. It is important to learn how to hone observation skills, so you know what to look for when interacting with a client. Documentation provides a record of what we are doing, the occupational profile of the client, and outcomes. Documentation has four main parts, known as a SOAP note. The subjective involves what people report and what someone is telling me; not what I think as the clinician. Objective is what I have seen in the evaluation and the intervention. The assessment/analysis is where we as occupational therapists prove our worth by interpreting the subjective and objective, which is the whole why of OT. The plan is where we have what we have seen and heard and what we think about it, and now we determine what intervention would be best for the client. Documentation is necessary whenever an OT interacts with the client and provides justification for OT services and the distinct value of OT. Documentation is important because if we don't document it, then it didn't happen.