Communication, Documentation, and Interprofessional Collaboration
Domain 6 examines communication, documentation, and teamwork as clinical skills. Items ask what to say, to whom, in what form, and how to document it defensibly.
Core rules
- Communicate for the audience: plain language and teach-back with clients and families; concise, outcome-focused reports to payers; structured handoffs to colleagues.
- Documentation should be objective, timely, accurate, complete, and attributable. Record observations, client goals, education, response to intervention, and reasons for changes. Avoid labels, speculation, and copied-forward notes.
- Use recognized formats such as SOAP or DAP when required, but the content matters more than the letters. Link assessment to plan and outcome.
- Interprofessional collaboration requires role clarity, shared goals, and respect for each discipline's scope. Use SBAR for urgent handoffs: situation, background, assessment, recommendation.
- Protect privacy in messages, meetings, and shared spaces. Confirm the client's understanding and preferred communication method.
Worked example
An OT is handing off a client with a traumatic brain injury to nursing before transfer. SBAR: the client is agitated when approached from the left; background includes a left neglect and noisy ward; assessment is fall risk during transfers; recommendation is to approach from the right, reduce noise, and use a two-person transfer. The note records the same objective details and the client's response.
Traps
Writing subjective judgments as fact; omitting client education or refusal; using jargon with families; failing to document handoffs; and speaking for another discipline's assessment. Also avoid sharing identifiable details in corridors or group chats.