Occupational Therapy: A Case Study

What do you do if you make a mistake or want to change documentation in a patient’s chart?
Documentation is one of the most important features in occupational therapy as the therapist must be able to demonstrate the need for services. The insurance companies will be looking at their recipient’s medical services. If they see anything inconsistent or that does not deserve payout, they have the right to refuse payment. This will get any therapy practitioner in trouble with their potential job. If the therapy practitioner realizes that they made a mistake, or need to make a change, they must be able to correct their error in a timely manner so insurance companies will pay out. Within Guidelines for Documentation of Occupational Therapy article,

it only stated the error was noted and signed. Is that all that needs to be done? Further research did not contribute too much unless it was the patient trying to change their own chart. However; an article published by Physician Practice called Making Changes in Charts?, had a few more tips. The initial tip was to document correctly the first time by rereading whatever you write before submitting. The article did say never to destroy any records because it could be considered malpractice. The only reason to rewrite a note is if you are not finished the note in the first place. For instances, if you are in the middle of it and realize a mistake, you can restart another one. The article did state not to use any correctional fluids such as white out and never mark out a mistake to wear you could not read it. People should only draw a single line threw the mistake and write underneath or beside it. Then the medical practitioner should sign and date whatever revision they made. Finally, documents should never be disposed, only archived in case years later someone wants to see them.