The Importance of Documentation

Throughout our class meetings, we have heard several times about the importance of documentation, which is recording the therapy session between the occupational therapist and the client. Documentation may include progress of the client, interventions that were completed that day, issues the client might be facing, etc. This is essential in part of being a successful occupational therapist. It's also important to document, in order to show proof of a therapy session, just in case it needs to be referenced. Documentation should be done after seeing the client, so information is not forgotten throughout the day and not simply drawn from memory. Documentation is also important for insurance and liability purposes. If a client you work with is suing for legal reasons, your documentation is important for lawyers, judges, and even jurors. For example, if something that happened during a therapy session is referenced in court, your documentation as the client's occupational therapist is important evidence that can be used for or against the client. Therefore, documentation is important, not just for the sake of recording vital information from the therapy session, but in case it needs to be referenced for legal purposes.