Accurate and well-structured clinical documentation is crucial for occupational therapists, particularly when conducting a Paediatric Functional Capacity Assessment. This form not only serves as a comprehensive record of a child's capabilities but also guides intervention planning and coordination with other healthcare providers. Below, we will walk through the essential sections of this assessment form, demonstrating the correct way to write and format each component using Emily Johnson's case as an example.

Child’s Information

Begin by clearly documenting the child's personal information, which provides context for the evaluation. For Emily Johnson, you would include:

• Full Name: Emily Johnson

• Date of Birth: 15/04/2015

• Age: 8 years and 6 months

• Gender: Female

• NDIS Number: 123456789

• NDIS Plan Dates: 01/01/2023 - 31/12/2023

• NDIS Goals: Improve social skills, enhance fine motor skills, increase independence in daily activities

• Immediate Family: John Johnson (Father), Sarah Johnson (Mother), Michael Johnson (Brother)

Referral Information

This section should detail the reason for the referral and relevant diagnoses. For example:

Emily was referred due to concerns about delayed fine motor skills and social interaction difficulties. Diagnoses include Autism Spectrum Disorder as the primary diagnosis and Sensory Processing Disorder as a secondary diagnosis. Her paediatrician is Dr. Lisa Carter, contact: 555-1234. There is no known family history of similar conditions.

Medications

Clearly list any current medications to avoid potential interactions or complications during therapy. In Emily's case, she is not on any medications, so you would note:

Current Medications: None
Medication Management: N/A

Family Factors/Informal Supports

Understanding the child's family environment and support systems is vital. For Emily:

She lives in a two-parent household with one sibling. The home environment is spacious with a dedicated play area. Support systems include weekly occupational therapy and monthly family counseling. A recent move to a new city is noted as a family dynamic or stressor. The current living environment is a detached house with a backyard.

Formal Supports

Document all formal supports and therapies the child receives to ensure coordinated care:

Emily's general practitioner is Dr. Mark Lee, contact: 555-5678. She sees specialists such as Dr. Anna Smith, a speech therapist, contact: 555-8765. Support workers like Jane Doe visit twice a week for additional assistance. Emily participates in weekly speech pathology sessions and monthly psychology sessions for emotional regulation. She also attends weekly art therapy sessions.

Early Years/Developmental History

Detailing developmental milestones helps in identifying areas of delay or concern. For Emily:

• Full-Term Pregnancy with no complications

• Sitting Independently at 8 months, Crawling at 10 months, Walking at 15 months

• First Words at 18 months, with delays in speech and social interaction noted at age 3

Activities of Daily Living (ADLs)

This section evaluates the child's ability to perform daily activities. For Emily:

She cannot dress or bathe independently and struggles with buttons and zippers. She is toilet trained but needs occasional assistance with wiping. Emily requires assistance with hair brushing but can brush her teeth with supervision. She can feed herself with utensils but needs help cutting food.

Instrumental Activities of Daily Living

These are more complex activities related to independent living. Emily can set the table with guidance but struggles with managing personal belongings and requires support for money management and transportation.

School Performance and Participation

Understand the child's engagement and support needs at school. Emily struggles with attention and following instructions, requiring one-on-one support.

Cognition and Communication

Evaluate cognitive functions and communication skills to tailor interventions. Emily needs assistance with planning, problem-solving, and managing impulses. Her expressive language is limited, and she uses gestures.

Social and Community Participation

Highlight participation in social activities and community support. Emily participates in a weekly community playgroup and is shy around strangers but engages well with familiar people.

Emotional Regulation/Self-Regulation

Assess emotional responses and strategies for managing emotions. Emily becomes frustrated easily and uses deep breathing techniques for self-regulation.

While meticulous documentation is indispensable, it can be time-consuming for occupational therapists. This is where AI medical scribes like Notis AI Medical Scribe come into play. Notis offers a robust solution by automating the documentation process, allowing occupational therapists to focus more on patient care rather than administrative tasks. By leveraging advanced voice-to-text technology, Notis transcribes patient interactions into structured SOAP notes, which are essential for documenting clinical notes efficiently.

Key benefits of Notis include significant time savings, with users reportedly saving up to 2 hours per day. This reduction in documentation time not only boosts productivity but also helps alleviate burnout among healthcare professionals. With its high transcription accuracy and seamless WhatsApp integration, Notis ensures that occupational therapists can maintain high documentation standards without additional effort.

Incorporating AI medical scribes into an occupational therapist's workflow transforms how patient documentation is managed, offering a streamlined and effective approach to capturing critical patient data. This innovation supports therapists in delivering better patient outcomes through more focused and personalized care.