Q&A with Cathy Brennan, MA, OTR/L, FAOTA

We asked AOTA members to share their biggest barrier to getting their work done—more than half said it was documentation. Documentation is essential for occupational therapy practitioners, even if it does take up a large portion of their time. Effective documentation is not only the key to reimbursement, but it also allows occupational therapy practitioners to articulate the profession’s distinct value.

Cathy Brennan, MA, OTR/L, FAOTA, has experience with effective documentation on both sides of the fence—she’s recommended denial or acceptance of cases for reimbursement as the Coordinator of Peer Review for the Minnesota Occupational Therapy Association for 30 years, and she also helps occupational therapy practitioners learn what to document so their cases will not be denied.

We asked Brennan to share a few tips and strategies for occupational therapy practitioners to be more effective in documentation.

AOTA: In your opinion, what is the most common mistake that occupational therapy practitioners make in documentation?

Brennan: The most common mistake I see is therapist documentation that includes everything but the kitchen sink in hopes that something will allow the case to be paid. My goal in documentation workshops is to write better, not more. Knowing what is needed to tell the story of medical necessity and functional outcomes is the key to documentation that gets reimbursed.

AOTA: How can occupational therapy practitioners get the most out of electronic documentation systems?

Brennan: Electronic documentation is only as good as the options it provides to allow therapists to “tell the story.” The key to a good electronic system is the ability to individualize patient reporting. I have seen too many cases where the cut and paste documentation looks the same for each client. My advice to therapists is to be engaged with the designers of the system and demand options that allow them a variety of choices for describing client responses and functional outcomes tailored to the individual client.

AOTA: What are your tips for occupational therapy practitioners doing point-of-service documentation?

Brennan: When my own internist began point-of-service documentation I felt disconnected as she sat and typed and never looked at me. I eventually had a talk with her and described that I felt depersonalized after 25 years of coming to her. Therapists need to develop skills in keeping the focus on the client, not on typing results. They should have good eye contact when asking questions and explain what they are typing so the client understands and feels connected to what is happening.

AOTA: What are your do’s and don’ts for successful documentation?

Brennan: One “do” is to be sure that your evaluation includes a baseline of functional performance. Without a baseline, change cannot be measured. One “don’t” is using the term “age appropriate” as an outcome goal with developmentally delayed children who will probably never achieve this but will develop functional skills.