Posted in Assistive Technology, Occupational Therapy

Using Microsoft OneNote for Documentation on the Run

Many therapists are looking for a way to document on the run.  This means that they are looking for a way to become paperless, much like many other professions.  This saves the mounds of paper that over the course of the years has become insurmountable.  I frequently talk about using MS OneNote for all of these documents.  Not only can you create a template like this one.  You can also print out your documents for immediate submission if you have access to a printer.  In the event that you do not have access to a printer, you can certainly e-mail it through a HIPPA compliant service, like hushmail.com.

This is a portion of the template that I use for evaluations in OneNote
This is a portion of the template that I use for evaluations in OneNote.

 

If I really need to print out a report for one of those meetings that are occurring today, you can absolutely do so.

This is the screen that allows you to see what your quick report will look like.
This is the screen that allows you to see what your quick report will look like.

 

You can do the same thing with your Medicaid notes and many other note forms that you will need.  I have never had to use a specific form for a consult but I developed one anyway for me to keep track.  Each of the cells in these tables will expand to the size needed, once you start entering information.

My own consult note form.
My own consult note form.

This is the note form that I created for my Medicaid notes.  It works well and is accepted by any agency that I work with.

Medicaid Provider Session Note Form
Medicaid Provider Session Note Form

I do not find it as easy to create templates in the free version of Evernote.  I am a OneNote girl!

 

Enjoy your weekend,

 

Eleanor

 

 

 

Author:

I am an occupational therapist with 18 years of experience in the pediatric sector, much of that time as an independent contractor. I am very passionate about my work and my writing. My degrees include a Bachelor’s of Science in Health Sciences and a Master’s of Science in Occupational Therapy from Touro College. Since graduating as a non-traditional student, I have worked in a variety of settings throughout the life span but settled in the area of school-based therapy. My interests lie in the area of using technology to support independence and I often train students to use programming not only to monitor their own goal progress but also support educational, vocational and life skills. Another area of particular interest is documentation. As an independent contractor for many years, I feel that it is important to align methods of documenting goal progress with educators for greater consistency and understanding when writing for an IEP. It is better to plan a format for documentation used in the IEP, such as for assessment and goal progress and that a rubric, in many ways, fulfills the need for consistency in documentation across all domains. Combining my interest in technology and documentation, I use Microsoft OneNote to maintain all documentation. I create a digital notebook for each student or patient with any forms required uploaded as templates which can then be completed, and saved automatically. I strongly believe in student centered approach to therapy. Students must be active participants in developing goals and documenting progress. In order to help students understand their progress, I teach my students to develop electronic portfolios and to use spreadsheet programming with graphs to collect data and view progress, whenever possible.