Clinical Observation & Documentation

During class today, we learned about Clinical Observation and Documentation. It made me very thankful for my past experiences that allowed me to get some practice in both subjects. During high school, I took a lot of health science courses and we spoke a lot about what to do if an error is made during documentation, so I learned to be in the habit of that. During my undergraduate career, I majored in Therapeutic Recreation (which is very similar to OT). During our classes, we learned about the importance of objective language. I had an internship working with individuals with special needs, and my coordinator forced us to document every client we worked with. While I hated it at the time, I now realize how beneficial this was in preparing me for being an OT. At the end of my internship, my coordinator had me go back and compare the notes I was writing then with the notes I had written at the beginning of my time there. I was terrible when I started! It was honestly embarrassing to read what I had written just several months before. My coordinator used it as a teaching moment to show me how much practicing helps with being a clear and concise documenter. I’m thankful for all my experiences that exposed me to skills I will need in my future career.