Instructions: Clinical Documentation Notes (e.g. SOP, DARP, PCARE Notes)

The purpose of practicing Clinical Documentation:

• Record experiences with client care.
• Use entries to prepare for and reflect on participation with treatment activities.
• Examine the clinical significance of the client’s condition and current functional status to the identified goals and selected treatment activities.
• Demonstrate ability to accurately document according to guidelines of facility.

Student will submit only a signed OTA&PTA Clinical Documentation & Caseload Management Form to the required ECentennial Drop box at the end of placement to verify documentation. The documentation completed on placement is NOT to be submitted to Centennial College. 

If required the following document includes the student and Clinical Supervisor instructions, examples, and blank template to be used as a worksheet for practice.

CLINICAL-DOCUMENTATION-INSTRUCTIONS PLUS EXAMPLES AND TEMPLATE