In OT documentation, where is progress toward goals typically recorded?

In OT documentation, where is progress toward goals typically recorded?

• A. Plan of care
• B. Assessment
• C. Intervention Notes
• D. Discharge Summary

Answer: (B)

Progress toward goals is captured in the assessment, which summarizes current status, changes over time, and how data from observations, assessments, and daily activities relate to the established goals. This section interprets progress, notes whether goals are being met or need adjustment, and justifies any modifications to the plan. The plan of care sets up the goals and overall approach, but it isn’t the place where ongoing progress data are synthesized. Discharge summaries describe outcomes at the end of care, not the ongoing progress trajectory. Intervention notes document what happened in individual sessions, but the broader progress toward goals is interpreted and recorded in the assessment.

Progress toward goals is captured in the assessment, which summarizes current status, changes over time, and how data from observations, assessments, and daily activities relate to the established goals. This section interprets progress, notes whether goals are being met or need adjustment, and justifies any modifications to the plan. The plan of care sets up the goals and overall approach, but it isn’t the place where ongoing progress data are synthesized. Discharge summaries describe outcomes at the end of care, not the ongoing progress trajectory. Intervention notes document what happened in individual sessions, but the broader progress toward goals is interpreted and recorded in the assessment.