What is the primary purpose of documentation in occupational therapy?

The primary purpose of documentation in occupational therapy is to provide justification for occupational therapy intervention. Documentation serves as a crucial tool for occupational therapists to articulate the reasoning behind the selected treatment plans and interventions. It outlines the patients' needs, goals, and therapy outcomes, ensuring that the interventions are evidence-based and tailored to individual client requirements.

In the context of healthcare, proper documentation supports continuity of care among practitioners and serves as a legal record that can substantiate the necessity of the therapies provided. It guarantees that there is a clear understanding of the patient’s progress, the effectiveness of interventions, and allows for communication among the healthcare team members.

While aspects such as billing are important, and summarizing patient progress and collecting feedback are relevant to improving therapy, the core intent of documentation is to create a robust and justifiable record of therapy interventions that aligns with professional standards and the specific needs of the clients. This enables both care accountability and enhances the quality of care delivered.