Practice Answer: What should an OT include in a Support at Home report?

Clear answers to common questions about occupational therapy practice in community aged care and Support at Home.

An Occupational Therapy report under Support at Home should clearly explain what the person is having difficulty with, why it matters, what is recommending, the intended outcomes and benefits, as well as how the recommendation relates to the person's needs and goals.

There is no benefit in making a report longer simply to make it appear more comprehensive. The goal is to provide enough clinical reasoning for the reader to understand and act on the OT's recommendations.

Who is the audience?

Before writing, consider who will actually use the report.

In Support at Home, your report may not solely be viewed by the care partner/registered provider. However, it could also be provided to the assessment agency or Services Australia. This matters because what they are looking for may be different things.

Assessor - does the report give me enough information to discern whether there has been a signficant change in need and a re-assessment is required? If not, does the report clearly justify why a specific tier is required?

Care Partner - does the report support the program evidence requirements and align with our obligations under the aged care quality standards?

Services Australia - does the documentation act as evidence that validates the business claiming rules?

What should the report communicate?

The content will vary according to the purpose of the assessment, but a useful report will generally communicate:

• the reason for referral and relevant client goals

• relevant functional abilities and difficulties

• the impact of the person's health, environment and circumstances on everyday activities

• identified risks and relevant contextual factors

• the OT's clinical reasoning

• recommendations and their intended outcomes

• relevant alternatives considered

• any further assessment, trial, quotation or follow-up required.

Where assistive technology or home modifications are being recommended, the documentation should also provide sufficient evidence to explain why the intervention is required and how it addresses the person's assessed need.

Avoid documenting simply because you assessed it

Not every piece of information gathered during an OT assessment needs to appear in the final report.

A useful test is:

Does this information help the reader understand the person's need, the clinical reasoning, the recommendation or what needs to happen next? An Initial Assessment and Report format that is efficient to complete and defensible is the most effective in Support at Home. If it does not, consider whether it needs to be included.

Good documentation is not necessarily detailed documentation. Under Support at Home, OTs need to balance efficiency with sufficient clinical reasoning and defensibility.

Practice takeaway: Write for the decision or action your report needs to support, rather than documenting every component of the assessment in the documentation template you provide - which might be viewed by many audiences.