Documentation: Outpatient vs Inpatient

One major difference I have noticed from spending time in both inpatient and outpatient pediatric settings this fall is the various methods of documentation that exist in the world of therapy.

At our hospital, we use a system called EPIC for online documentation.  Within this system, there are templates created for occupational therapy.  Each template is geared towards a population we may be treating.  For example, there is a pediatric template along with a NICU template.  These have been created to increase efficiency and ease of documentation.  The information within each template is relevant to the population you are treating.
I have been learning how different it is to document for the pediatric population, especially within the NICU.  I have been learning a whole new language to communicate through it seems! We are documenting what we gather from evaluations/assessments along with what treatments we provide and the rationale for our services.  Within the acute setting, another role we have is to determine the next level of care we feel is needed.  This may include going to an inpatient rehab facility to continue building strength and independence in ADLs, receiving outpatient services or even OT within the home.  We may also be suggesting adaptive equipment for the child and family to utilize at home to increase independence and safety, such as a commode or shower chair.  These are all pieces of information we include within our online documentation system.

The outpatient documentation that I have observed during this rotation has tended to be much more narrative form. It had been based off of a SOAP note format.  This means that there is a subject, objective, assessment, and plan portion of the note.  Goals are frequently revisited to document progress made.  Both settings take into account ADLs that are being addressed (if age appropriate) or developmental aspects that are requiring therapy.  In the outpatient setting, parents are typically very involved with the goals and home programs are crucial for progress to be evident.  As one therapist explained to me, there is only so much you can do in a 30-45 min session each week.  So much depends on the work that is done at home and involvement of the parents.  This is another reason why education is huge for parents so they truly understand what we are doing and how this can benefit their child.  If we explain ourselves and parents understand the strategies they use, they will often times feel more confident carrying through with home programs.

Being able to expand my skills set and broaden my documentation skills throughout this rotation has been great so far and I look forward to continuing to develop my skills!!