Check the Accuracy of Your Information
Checking for accuracy is a simple first step in reviewing your record. Your therapy may not be as effective as possible if your therapist is working with faulty information. An important place to check for accuracy is your evaluation. Your OT will record and overview of pertinent health information and your current situation. Is your history accurate? Did your therapist miss something that you believe to be relevant to your situation?
Understand Your Goals and Treatment Plan
Your therapist should be clearly communicating your goals and treatment plan with you. If this isn’t happening to any extent, you may not be with the right OT. More likely, though, your therapist is explaining these, but as a consumer, it can be difficult to retain all of the information in a session. Or perhaps your therapist did not thoroughly explain her plan as she does in her documentation. Either way, it can be helpful as a patient to sit down with a written version of your goals and treatment plan. In an evaluation, you should find your goals, a time frame for achieving them, and strategies for getting there.
Understand Your Progress
Each note following the evaluation should relate back to your goals and the progress you are making toward them. Often these goals are broken down into long-term and short-term goals. There are typically 3-5 goal areas that your therapist is working toward. They should be measurable and meaningful to you. Again, your therapist should be verbally updating you on your progress, but it can be helpful to spend some time with a written record so you can be self-monitoring your progress.
Have Documentation Handy for Future Health Care Providers
This last area may not impact your current course of treatment, but can be extremely useful for future therapy you receive.
I recommend asking for a copy of your notes when your treatment is complete, especially if there is a chance you will need occupational therapy again in the future for a related condition, such as in the case of chronic conditions.
You can then bring in these old occupational therapy notes whenever you start a new episode of care. Having access to past records allows your therapist to jump-start your treatment, by gaining a better understanding of the course of your condition, what has worked in the past and what hasn’t. Some institutions will automatically issue you a discharge summary, which will neatly summarize your visit. If you don’t receive one, don’t be afraid to ask for one.