Background

Stella works for a community organization providing occupational therapy services in clients’ homes. As part of the organization’s community outreach, they asked her to develop and run group education sessions at local community centres for adults with dementia and their caregivers. As Stella puts together the outline for the group, she needs to determine how this group intervention will be documented

She consults one of her occupational therapy colleagues who facilitates group interventions in a large hospital organization. Stella learns that her colleague documents the hospital group sessions in each client’s individual clinical record. That group is part of a fall prevention program that involves guiding participants through a series of standing balance activities. For that type of group, the occupational therapist completes documentation after each session that includes details about the client’s participation, their response to the intervention, any unexpected events and if any modifications to the activities or adjustment of individual goals are required.

Stella wonders if she is required to document in the same format and decides to review the College’s Standard for Record Keeping.

Considerations

Occupational therapists must document the group interventions they provide. Since there can be variability in the format, structure, and goals of group interventions, there can also be variability in occupational therapists’ documentation.

To determine what and how to document, occupational therapists should consider the following questions:

• What is the purpose or nature of the group?
  • For example: treatment vs. education
• What is the level of risk to the client?
  • For example: psychotherapy vs. caregiver support
• What is the format of the group?
  • For example: drop-in vs. referral
• Will another health care provider co-facilitate?
• What information is available and relevant to include?
• Are there any organizational policy requirements?
• What are the expectations under the Standard for Record Keeping?

What to Document

The Standard for Record Keeping indicator 3.4 states that at minimum, occupational therapists are expected to “Document relevant clinical information about group therapy in which clients participate (for example, stated goals, client insights, and adverse events).

Notes may be made in individual client records or in a group record, such as a file containing a group’s purpose, duration, attendance, and resources provided.”

Occupational therapists should consider including details (if applicable) such as:

Scope and Context of Group

• The type of group
  • For example: one-time education session, weekly reoccurring group, drop-in, or registration/referral
• The goals of the group, including the goals of each session if it is a reoccurring group
• Location and duration of the session(s)

• Attendance (can be documented on a separate sheet if it is an education session, or in each client’s clinical record if recommendations are provided or individual occupational therapy goals are addressed)

• Any unexpected or adverse events that occurred in the group
• Any other information as required by the organization/employer

Assessment and Intervention

• Any observations by the occupational therapist
• Any individual progress towards goals or any modifications to the goals
• Individual or overall feedback from the participants
• The information that was provided to participants
  • For example: handouts, presentations, strategies discussed, or recommendations provided)

How to Document

Depending on the purpose and goals for participating in the group, there may be different levels of risk to the client. For example, a group where participants receive individual assessment or intervention (such as psychotherapy or cardiac rehabilitation) may carry more risks than a group that provides general education (such as an information session on community resources).

Individual clinical records
For groups where participants receive individual assessment/intervention or have an increased level of risk, separate individual documentation is likely required for each person in the group.

For example, noting specific goals for the client, progress, concerns noted, adverse events, and recommendations. There may also be an organizational requirement to document in individual records in these situations. 

One group note/file
Documenting the collective experience of the group in one note may be sufficient where the risk is low. For example: in drop-in groups where the focus is on providing general education.

Including an attendance list, handouts/resources, high level notes on the overall experience, or summary comments from the group, would all be considerations that could be included in documentation. There may also be less information available to document for drop-in groups. 

Documenting groups that are co-lead with others

Occupational therapists should decide in advance with the other group facilitator(s) how the documentation will be completed. Each provider may choose to document their own notes, or one provider may take responsibility for documenting an interprofessional note.

The Standard for Record Keeping, indicator 4.3 states that “Where there are shared and overlapping roles and responsibilities with other professionals and combined reports are created, identify the portion of the report for which the occupational therapist is responsible. If there is no clear delineation, the occupational therapist is accountable for the entire report.”

Factors to consider may include the role, responsibility, and scope of practice of each facilitator as well as any organizational policy requirements for documentation.

Outcome

Stella reflects on what she learned in comparison to the group intervention she intends to provide. She concludes that her education sessions are low risk with general learning goals for the group. She develops an outline that documents the purpose and goals of the group as well as the type of clients who are best suited to participate. Her outline includes:

• The format of weekly education sessions that will focus on different aspects of home safety and community engagement. 
• The documentation process where she has determined that one note can be completed after each group session describing the collective experience of the participants.
• A template for the group note to ensure that the relevant information is documented after each session. 

Stella checks with her manager to confirm that this would meet the organization’s documentation requirements. She works with her manager to set up a system at the organization to securely store this information for future reference and in accordance with the privacy legislation.

Conclusion

Occupational therapists are expected to consider the context of their practice in the application of record keeping standards for group documentation. Group documentation must include any handouts or resource materials provided. Occupational therapists must also ensure the security and confidentiality of the group documentation and comply with any organizational policy requirements.

Contact

If you have any questions about this case, or have any ideas or requests for future cases, contact the Practice Resource Service: 1-800-890-6570/416-214-1177 x240 or [email protected].

Want more case studies? Sign up to stay up to date and receive the latest cases when they’re released.  

← Back to Case Study Archive