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Mar 24, 2026
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OTAS 206 - Communication and Documentation Essentials in Occ. Therapy
PREREQUISITES: OTAS 201 Fieldwork Level 1-A; OTAS 202 Occupational Performance in Pediatric Care; OTAS 203 OT in Mental and Behavioral Health; OTAS 204 Health and Wellness Promotion in OT; OTAS 205 The Role of OTA in Interdisciplinary Health
COREQUISITES: OTAS 207 Fieldwork Level 1-B
CREDIT HOURS MIN: 1
TOTAL CONTACT HOURS MIN: 16
Explores and allows practice for essential communication and documentation skills required in OT. Defines and describes skills, techniques, and processes for effective communication and accurate documentation, which are cornerstones of high-quality, evidence-based OTA practice. Skills reviewed and developed will ensure seamless collaboration between supervising OTR and among healthcare teams and highlight the importance of safeguarding patient confidentiality, safety, and meeting legal and ethical standards. Critical aspects of communication and documentation in OTA, its importance, and best practices and protocols will be reviewed and practiced, with implications for legal and ethical practice highlighted. Emphasis placed on professional intra- and interprofessional interaction in both a virtual learning environment and during Fieldwork Level 1 and beyond.
MAJOR COURSE LEARNING OBJECTIVES: MAJOR COURSE LEARNING OBJECTIVES & OUTCOMES: Upon successful completion of this course, the student will be expected to:
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Using effective communication skills, communicate the distinct nature of occupation and OT practice to a variety of audineces [B.2.5].
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With references to essential documents within OT practice, identify and describe the importance of effective, timely, accurate communication [B.3.2] and legal and ethical implications [B.3.10].
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Demonstrate knowledge, awareness, and understanding of legal and ethical implications regarding patient privacy/confidentialty rights and laws (i.e. HIPPA, FERPA, etc.).
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As part of an OT practioner’s personal and professional responisibilities and roles, explain your process or strategy for evaluating, refining, and updating your personal and professional development tools (PDTs) [B.2.9].
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Identify and demonstrate principles of effective communication in a variety of formats (verbal, nonverbal, written, etc.) in various settings within diverse populations; describe your professional reasoning [B.3.2] regarding how you would tailor your approach and implement theraputic use of self [B.3.1].
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Explain and demonstrate the importance of effective communication and documentation skills from a legal and ethical standpoint [B.2.9; B.4.3; B.4.4; B.4.5].
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Explain and demonstrate the importance of effective ethical and legal communcation and documentation skills when performing tasks related to reimbursement, coding, and billing [B.2.10; B.4.3; B.4.4].
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Explain and demonstrate the importance of effective ethical and legal communication and documentation skills when reporting data to a supervising OTR [B.2.10; B.3.5; B.4.9].
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Explain and demonstrate the importance of effective ethical and legal communication and documentation skills as they relate to intra-/interprofessionalism and interdisciplinary care team dynamics and collaboration [B.2.4; B.2.5; B.2.9; B.2.10; B.3.21; B.3.22; B.4.6
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Explain and demonstrate the importance of effective ethical and legal communication and documentation skills when advocating for a service or a product [B.2.9; B.2.10; B.4.2; B.4.4].
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Demonstrate knowledge, awareness, and understandong of legal and ethical implications using Electronic Health Records (EHR)/Electronic Medical Records [EMRs] systems.
COURSE CONTENT: Topical areas of study include - COURSE CONTENT: Topical areas of study include the following:
- Review of essential OT documents and how they address legal, ethical, and professional communication and documentation standands in practice.
- Professionalism essentials, including personal, practice, and technical skills.
- Communication and documentation principles during:
- Charting/chart review
- Note writing
- Patient history procurement/data-intake
- Record-keeping
- Coding, billing, insurance verification, and for reimbursement.
- Explores patient, family, and professional communication techniques and strategies, including non-verbal and verbal communication.
- Appropriate body language
- Communication via electronic methods
- Patient and consumer education and teaching.
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Patient and consumer education and teaching. Will review components of occupational therapy assistant documentation (i.e., SOAP note, EMR platforms) necessary to ensure ethical and legal compliance for the reimbursement of services.
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