In the dynamic realm of school-based occupational therapy, daily session notes are both a nuisance and a blessing. These notes serve a multifaceted purpose, acting as a tangible record of student progress, a conduit for communication with teachers and parents, a means of demonstrating the effectiveness of your interventions, and, in the most unfortunate cases - a way to cover your own behind when everything hits the fan.
As they say, if it's not documented, it never happened.
For that reason, in this essay, we'll delve deep into the world of daily session notes, exploring the why, how, and what so you can streamline your documentation process and elevate your ability to document what you practice.
I'll also show you a few examples you can use to craft your own note template in the style you prefer.
Let's get started.
Table of Contents
Section 1: Why Do School-Based OT Practitioners Need to Take Notes?
To get started, you need to understand the why behind taking notes. I mentioned a few reasons in the intro, but I want to cover each of these reasons more so you recognize the importance of each.
Tracking Student Progress
Daily notes allow you to show a longitudinal view of each student's journey, helping you to identify and share with the team trends and patterns in the student's development. This insight is invaluable for tailoring interventions and demonstrating progress over time.
You may embed your data directly into your note or use a separate data collection form to track the data before narratively adding the data to your notes.
Detailed notes are also your proof of efficacy. They show the direct impact of your interventions on a student's functional abilities. This can be instrumental when justifying your role and services to administrators, parents, and other stakeholders.
On the flip side, your notes can also be used to show why a student may NOT have made progress. They may have had a lot of absences, or perhaps the teacher prevented you from seeing the student. Whatever the cause, your notes are the place to document it.
Daily notes help ensure compliance with federal and state regulations and Medicaid billing. They provide a clear record of services rendered, which can be crucial in audits or reviews. Every state operates differently, so check in with your supervisor for what is required in your notes.
Cover Your... Behind
And if those reasons are not enough to get you to complete your notes, this one should be. Your notes are your most valuable defense when someone claims that you or the district has done something improper.
Whether someone claims you never saw the student, that they don't believe the student's progress, or anything else, your notes can be your best friend. If you don't take notes, or you take poor notes, they can also be your worst enemy.
Section 2: Options for Note Types
Now for the fun part (well, as fun as talking about notes can be). Let's explore the various note-taking models available. Here are five options:
SOAP Notes (Subjective, Objective, Assessment, Plan)
SOAP notes are a comprehensive model organized into distinct sections. The Subjective section captures information provided by students, teachers, or parents. The Objective section contains measurable data and observations. The Assessment section summarizes your professional evaluation, while the Plan outlines future interventions and steps.
SOAP Note Example: Subjective: While walking to the OT room, the student shared that she was having a rough day and that her hand was tired from writing a 3 paragraph paper in class earlier. When asked what she does when her hand gets tired, Sarah noted that she sometimes takes breaks and shakes her hand to relieve the pressure. Objective: During the session, the therapist observed that Sarah used a very tight grasp on a writing tool but relaxed her grip when writing on a vertical surface. Assessment: After writing on a vertical surface for 5+ minutes, Sarah had no complaint of hand fatigue. In fact, she wanted to continue the story she was working on. Plan: In the next session, I will introduce a slant board to see if this has the same effect on Sarah's tiredness during writing activities. If helpful, I will consult with the teacher to determine if a slant board may be appropriate to use in the classroom.
My Take on SOAP Notes:
SOAP notes are comprehensive and tend to be longer than other formats. If you are new to school-based OT, consider starting with SOAP notes to ensure you hit on every crucial piece of the treatment session. As you become more experienced, you may move on to something like DAP notes, which can be quicker.
DAP Notes (Data, Assessment, Plan)
DAP notes focus on data collection, assessment, and planning. The Data section records qualitative and quantitative data and progress. Assessment summarizes your analysis, and Plan outlines future strategies.
DAP Note Example Data: Sarah reported having a rough day and hand fatigue. She mentioned using breaks and hand-shaking to relieve hand pressure. Observation: Sarah had a tight grasp on the writing tool but relaxed her grip when writing vertically. Assessment: Sarah's hand fatigue was non-existent when writing on a vertical surface - even after 5+ minutes. She desired to continue the activity, indicating increased comfort and reduced fatigue. Using a vertical surface appears to be an effective strategy for Sarah. Plan: Introduce and monitor the impact of the slant board on Sarah's hand fatigue during writing activities. If the slant board proves helpful, consult with the teacher to assess the feasibility of using one in the classroom.
My Take on DAP Notes:
DAP Notes are quick and efficient. They omit the "Subjective" piece, but as you can see in the example, you can add any subjective notes into a DAP note's "Data" section.
My notes tend to look like a narrative version of DAP notes due to saving space on a page. If you write your notes directly into an online system, you may not need to worry about spacing, and listing your thoughts out may be a perfect solution.
In goal-oriented notes, the primary focus is on the goals and objectives outlined in the student's IEP. These notes track progress toward these specific goals, making them particularly valuable for IEP reporting and compliance.
Goal-Oriented Note Example Goal: - Improve Sarah's hand comfort and reduce hand fatigue during writing activities. Objective: - Sarah reported a rough day and hand fatigue. - Observation: Sarah exhibited a tight grasp on the writing tool but relaxed her grip when writing on a vertical surface. - After 5+ minutes of writing on a vertical surface, Sarah showed no signs of hand fatigue and expressed a desire to continue the activity. Progress Towards Goal: - Sarah's ability to write without hand fatigue improved during the session. - The introduction of the vertical surface appears to be a successful strategy.
My Take on Goal-Oriented Notes:
This template fits the school-based OT model well, given the direct commentary on the student's goal. However, if you have multiple goals, you may have to add a similar note for each goal you work on that day.
I wouldn't say I like that the "Plan" piece is missing in this note type. If I were to use this template, I would add a "Plan" section to the note. It isn't necessary, but it makes my life easier when planning my next sessions.
These notes use predefined checklists or flowcharts to structure your documentation. They provide a systematic and efficient way to record information. Checklists ensure that you cover all necessary points during your note-taking.
I don't have an example of this for you because checklists tend to a) take up a whole sheet of paper or b) are built-in to an online system.
I have used strict checklist versions for notes in the past, but I was not a fan. They are just too rigid and never have the checkboxes you need. That leads to frustration while completing your notes and trying to fit a sentence or two wherever it will fit on the page.
Hybrid notes offer flexibility. They allow you to combine elements from different models to tailor your documentation to your needs. This can be especially useful when a student's needs are multifaceted and don't neatly fit into a single model.
While I'm not fond of checklist notes, a hybrid version incorporating a checklist with some space for narrative notes can work well. The checklist section can be used for some basic info (like where you saw the student and for how long), while the narrative section allows you to include your DAP section.
Want more help crafting the perfect note template?
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Section 3: How to Decide Which Note-Taking Model Is Right for You
The question now is, how do you choose the note-taking model that aligns best with your practice? Here are some factors to consider.
Nature of Students' Needs: Consider the specific needs of the students you work with. Some note-taking models may be better suited for particular types of interventions or conditions.
If you have a diverse caseload of students with different needs, you'll want to use a template that allows for flexibility. If you work on similar skills with many of your students, then a checklist may work out well.
Institutional Requirements: Your school or district may have specific documentation standards or templates you must use. Ensure that your chosen model aligns with these requirements.
Personal Documentation Style: Reflect on your personal preferences and documentation style. Some practitioners may find certain models more intuitive or comfortable to work with.
To make an informed choice:
Conduct a Self-Assessment: Reflect on your practice and preferences. Consider the factors mentioned above.
Trial and Error: Experiment with different models to see which feels most natural and effective for your daily note-taking. Which one allows you to provide the most relevant info without taking up half of your day to complete?
Seek Feedback: Consult with colleagues or mentors who may understand which model best suits your specific context.
Flexibility: Remember that flexibility is key. You can adapt your note-taking style as needed and may even choose different models for different students based on their unique needs.
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Section 4: Tips for Implementation
Creating a structured system for note-taking is a vital step in optimizing your school-based occupational therapy practice. To help you establish an efficient routine, consider implementing the following tips:
1. Schedule Time on Your Calendar:
Allocate dedicated time on your calendar for completing session notes. Treat this time as non-negotiable and prioritize it. Consistency in scheduling note-taking sessions will help ensure that you stay up-to-date with your documentation.
2. Create a Template:
Develop a note-taking template that aligns with your preferred documentation style (SOAP, DAP, etc.). A well-structured template can significantly reduce the time and effort required to document each session. Customize it to include essential sections and prompts relevant to your practice.
3. Use Snippets for Commonly Used Phrases:
Consider using text snippets or shortcuts for commonly used phrases and sentences. Many word-processing software and note-taking apps allow you to create and use shortcuts, saving you from repeatedly typing the same information. This is especially handy for phrases like "student demonstrated improvement in..."
4. Explore Technology with Google Forms:
If you prefer a digital approach, explore using technology like Google Forms for note-taking. Google Forms allow you to create customized forms with fields for each section of your notes. Responses are automatically organized, making it easy to review and store information digitally.
5. Prioritize Efficient Documentation Tools:
Invest in efficient documentation tools that align with your workflow. If you prefer handwriting notes, consider digital pens and tablets that can convert your handwritten notes into digital text. For digital note-takers, explore note-taking apps that offer templates and organization features.
6. Consider Voice-to-Text Software:
If typing is time-consuming, explore voice-to-text software. These tools allow you to speak your notes, which are then transcribed into text. This can be a quick and convenient way to capture your observations and assessments during sessions.
7. Regularly Review and Update Templates:
Periodically review and update your note-taking templates. As your practice evolves or you encounter new challenges, adjust your templates to ensure they reflect your current needs. Templates should be dynamic and adaptable.
If you read all the way to this point, first and foremost, thank you. I appreciate you spending your time here learning how to improve yourself as a therapist.
I hope you found this post insightful, and I hope it helps you develop a strategy for getting your notes completed efficiently.
Now, be sure to put one thing you learned from this post in action today. Then, please share this post on your social media page to help other school-based OT practitioners.
Thanks again for reading, and I hope you have a great day!
Until next time,