400907 Lecture Notes - Lecture 4: Formal Language

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Week 3 - Online Module
Documentation - Basic Guidelines
* Black pen
* Sign immediately after the last word. Then print your name and designation.
* Always place the patient’s full name and other personal details as required by the
organization.
* Do not erase errors, rule through the error (making sure that it is still legible) and
write the correct information above entry and initial and date the change.
* Date for every entry
* Documentation should occur as soon after the session as possible to maintain
accuracy
* Use formal language
* Use approved abbreviations as specified by the organisation
* Ensure your writing is legible
* Correct grammar and spelling
Documentation - Tips
- Use language appropriate for the reader.
- Proof read.
- Use dictionary.
- Follow guidelines and proformas suggested / provided.
Document only fact. 'What you saw, heard or did.'
Be objective not subjective
Initial Interviews
Most initial interviews are documented using a narrative format.
There is an introductory statement regarding the type of occupational therapy
intervention.
Distinguish between 'observation' and 'information' reported by the client
Initial Interview - Detail
The report is organised using headings.
For example.
- medical history
- social situation
- home environment
- prior functional status
- current functional status
- occupations- leisure, work, self care
- problem list
- goals
- action or intervention
- plan
Initial Interview - 'Sample Checklist Sections'
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