Skilled Care Tips Peds

Pediatric Quick Tip Guide for Documentation

Use These Tips to Document Skilled Care In Your Treatments!

Your Go-to Reference for Documenting Your Skill

Feeling overwhelmed writing your occupational therapy notes? We help make documentation easy for you! Use this quick tip sheet to create a documentation statement to help support your amazing services.

Level of Assistance

Independent
Supervision
Set-Up
Min

HOH (hand over hand)

Type of Assistance/Cues

Tactile

Verbal

Visual

Physical
Auditory

Frequency of Assistance

Trials
- Ex. 1/4, 3/4

Percentages
- ex. 80%, 90%

Numerical
- Ex. 2 verbal prompts, 3 visual cues

Level of Engagement/Participation

Full engagement: Child participated in the entire activity without losing focus.
Partial engagement: Child participated in parts of the task but required redirection.
Resistant: Child refused or showed behaviors indicating disengagement from the task.

Additional Thoughts to Consider

Fading
- Is the amount of assistance or prompting decreasing as the session progresses and the child becomes more independent with the skill?
Generalization
- Is the child able to transfer learned skills to other settings or tasks (e.g., applying skills learned in therapy to home or school)?
Consistency
- Is the child demonstrating consistent performance across different trials or sessions, or are there fluctuations in skill level or engagement?
Carryover
- Are the skills learned in therapy being carried over to home or school environments? Is the child able to apply these skills independently or with minimal assistance?
Attention Span
- How well did the child maintain focus throughout the session? Did their attention improve or decrease during certain tasks?
Behavioral Challenges
- Were there any behavioral difficulties that affected the session? What strategies were used to address these behaviors (e.g., redirection, sensory breaks)?
Task Complexity
- Did the complexity of the task increase or decrease based on the child’s performance? Were tasks broken down into simpler steps or combined into more complex activities as skills progressed
Motivation
- How motivated was the child during the session? Were specific reinforcements or rewards needed to increase engagement?
Physical and Emotional Fatigue
- Did the child demonstrate signs of fatigue (physical or emotional) during the session? How did this impact their participation or performance?
Environmental Factors
- Were environmental modifications (e.g., adjusting lighting, noise levels, seating arrangements) necessary to improve focus and participation?
Peer Interaction
- Did the child demonstrate improved social interactions or engage with peers during group activities or play?
Frustration Tolerance
- How did the child manage frustration or challenges? Were specific strategies used to help them cope with difficult tasks?

Words and Phrases to Show Skilled Care

Facilitated ....
Guided child for correct ...
Corrected position of ...
Educated parents on ....
Modified treatment secondary to ...
Adapted environment due to ...
Assessed home safety ...
Promoted independence in ...
Analyzed child's movement ...
Adjusted intervention ...
Engaged parent in ...
Stabilized ...
Reinforced ...
Progressed activity to ...
Directed parent in correct technique for ...
Established home activities with parent to ...
Compensatory Strategies used today secondary to ...
Child is at risk for ...
Redirected child with ...
Collaborated with ...

Examples Incorporating Skilled Words/Phrases

Assessed child’s movement patterns or cognitive responses during tasks.
Modified the task difficulty based on the child’s responses.
Increased task complexity to challenge the child’s skill level.
Integrated sensory, motor, or cognitive strategies to address multiple areas of need.
Strengthened emerging skills through repetition and positive reinforcement.
Worked closely with caregivers/teachers to ensure continuity of care across environments.

What to Avoid in Your Documentation

Tolerated well
Repetitive language
Observing
Encouraged
Supervising
Continue with POC

How to Edit Non-Skilled Phrases

Tolerated well: Rephrase as “Child demonstrated…”
Observed: Replace with an active description of what you did.
Participated: Be specific about the child’s level of engagement.
Performed well: Replace with objective performance measures (i.e., “Demonstrated improved fine motor skills by…")
Encouraged: Instead, specify the cue or method used to promote participation.
Good progress: Use objective metrics like percentages, trials, or qualitative descriptions.

Phrases to Structure Skilled Treatment

Utilized play-based activities to promote ...
Utilized a multisensory approach to improve ...
Developed fine motor skills through activities that targeted ...
Conducted feeding and oral motor assessments and developed individualized treatment plans to improve ...
Implemented handwriting programs to address ...
Used cognitive rehabilitation techniques to improve ...
Conducted environmental assessments and made recommendations for modifications to improve ...
Trained parents and caregivers in techniques to support ...
Provided education and training to school staff to support the carryover of ...
Implemented behavioral modification techniques to address ...
Used a strengths-based approach to identify areas of ...
Monitored progress through objective measurements, such as ...
Adapted interventions to meet the unique needs of each child by ...
Used therapeutic play to engage the child in tasks requiring bilateral coordination.
Implemented visual supports (i.e., visual schedules) to assist with task completion.
Assessed the child’s ability to engage in self-care tasks such as brushing teeth or putting on shoes.
Used social scripts to support turn-taking and reciprocal conversation during play.
Modified sensory inputs (i.e., dimming lights, adjusting noise levels) to support attention during activities.
Applied task analysis to break down complex activities into manageable steps for the child.

Additional Documentation Tips

Be specific: Focus on what specific therapeutic techniques or interventions were used and why they were necessary.
Highlight progression: Document any changes in skill acquisition, including how and why tasks were made harder or easier.
Focus on goals: Always connect the intervention back to a functional goal (i.e., what the child is working toward achieving in daily life).
Use objective data: Include measurable outcomes like percentages, number of trials, or qualitative descriptions (i.e., “improved grasp from 50% to 75% of trials”).

Documentation Examples for Specific Strategies

Sensory Integration Strategies

Desensitization techniques for tactile defensiveness
Sensory-based interventions to improve self-regulation and attention
Sensory diets created to meet the child’s unique sensory needs
Used vestibular input (i.e., swinging, spinning) to improve balance and coordination
Applied proprioceptive input (i.e., deep pressure, joint compressions) to promote body awareness

Play-Based Interventions

Pretend play: Used imaginary scenarios to improve social skills, turn-taking, and language development.
Gross motor play: Engaged in climbing, running, or jumping to improve coordination and muscle strength.
Fine motor play: Used activities like stringing beads or manipulating small objects to build hand strength and coordination.

Social Skills and Behavior Management

Modeled appropriate social interactions during peer play.
Reinforced positive behaviors using a token system or other behavior management tools.
Utilized social stories to help the child navigate social situations.
Used emotional regulation strategies to help the child manage frustration or anxiety.

Remember - focus on what SKILL you are providing that this child requires services for and the FUNCTIONAL goal you are working towards.

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