Occupational therapy (OT) consults are crucial for assessing patients' needs and planning interventions to enhance their daily living activities. Proper documentation of these consults is essential for effective communication among healthcare providers and ensuring continuity of care. This guide provides a step-by-step approach to writing and formatting clinical documentation for OT consults, followed by an introduction to how AI medical scribes like Notis AI Medical Scribe can automate and improve this process.

Effective OT consult documentation typically follows a structured format, often resembling the SOAP (Subjective, Objective, Assessment, Plan) note format. Here's how you can write and format an OT consult document using a detailed example:

This section includes the patient's reported experiences and concerns. For example, a patient might express difficulty in performing daily activities due to limited mobility.

Example: The patient reports difficulty in transferring from bed to wheelchair and experiences fatigue during morning routines. They express a desire to increase independence in daily activities.

Document observable facts and measurements. This includes assessments of the patient's physical and cognitive abilities.

Example: The patient demonstrates limited standing ability, requiring assistance for transfers. Current equipment includes an oval-shaped toilet with a 16-inch height, which complicates transfers.

This section includes the professional interpretation of the subjective and objective data. It identifies the patient's needs and potential interventions.

Example: The patient's limited mobility and current equipment setup contribute to decreased independence. Safety concerns are noted regarding transfers and risk of falls.

Outline the proposed interventions and follow-up actions. This may include equipment adjustments, scheduling routines, or therapy sessions.

Example: Plan to install a floor-to-ceiling pole for transfer assistance and trial a sliding transfer bench. Coordinate consistent Personal Support Worker (PSW) scheduling and explore funding for alternative equipment. Initiate a physiotherapy plan to improve strength and mobility.

In the fast-paced environment of occupational therapy, efficient documentation is vital yet time-consuming. This is where AI medical scribes, such as Notis AI Medical Scribe, become invaluable. Notis offers several features that streamline the documentation process:

Notis significantly reduces documentation time by automating the transcription of patient interactions into structured SOAP notes. This allows occupational therapists to save up to 2 hours per day, focusing more on patient care rather than paperwork.

The scribe operates directly through WhatsApp, ensuring a seamless integration into daily workflows without the need for additional software. This familiar interface simplifies the transition and enhances user productivity.

With 99% accuracy in voice-to-text transcription and support for 56 languages, Notis ensures precise and comprehensive documentation. It also provides smart search and retrieval features, enabling therapists to access patient records efficiently.

By leveraging AI technology, occupational therapists can enhance their documentation practices, ensuring accurate, timely, and efficient patient records while focusing more on delivering quality care. Notis AI Medical Scribe offers a robust solution to the challenges of traditional documentation, transforming how occupational therapy consults are documented and managed.