Introduction to documentation
Documentation of your assessment and intervention with infants will vary in content and structure depending on the following:
- Demands of your service / service guidelines
- Who the documentation is to be read by
- Purpose of documentation (e.g. for treatment planning, referral letter, for assistance with diagnosis, application for funding, home program for family)
- Who else is contributing to documentation (e.g. what is your role within the team)
Regardless of the audience, documentation should be presented in an occupational performance framework outlining your assessment and intervention across the occupational performance areas of:
- Engagement/Visual Interaction
- Self Care (feeding, grooming, dressing)
- Play/Leisure
- Productivity
- Sleep/Rest
- Sensory Regulation
