Importance of Documentation

When I first began shadowing occupational therapist, I remember meeting a girl who had recently graduated. She was very nice and constantly told me how much she loved her job. Towards the end of the day, I heard her in her office on the phone saying "the only bad part about this job is all the documentation". I have always wondered about what makes it so bad.

Regardless of how tedious and annoying it may be, documentation is a very important aspect for being an OT. This is crucial for ethical and legal reasons. Documentation is always important for insurance companies. If a practitioner is not properly documenting, their lack of proof could be the defining line of an insurance company continuing or discontinuing payments. It is also important to be able to efficiently and accurately treat the clients, by having the details of their previous sessions.

For me, I think one of the most important reasons to document is to be able to fully remember what happened in a session. My memory is not the best and I tend to forget little details very easily. In occupational therapy little details can be crucial to the intervention. In my school life, I tend to write everything down and it is more of a habit than a nuisance for me. I hope my habit of writing down all the details follows me into my career because documentation is such an important aspect of being an OT.

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