Acute Care Occupational Therapy: Clinical Reasoning, Patient Safety, And Professional Confidence

Editor's note: This text-based course is a transcript of the webinar, Acute Care Occupational Therapy: Clinical Reasoning, Patient Safety, and Professional Confidence, presented by Christopher Unkrich, MOT, OTR/L.

Please also use the handout with this text course to supplement the material.

Learning Outcomes

After this course, participants will be able to:

• Identify prioritization strategies and sound clinical reasoning to safely provide occupational therapy services in acute care.
• List common contraindications when working with patients with cardiovascular, neurological, orthopedic, and pulmonary conditions in adults in the acute care setting.
• Identify safe decision-making, decrease feelings of anxiety, and promote confidence by integrating useful approaches to interdisciplinary communication.

Introduction

I am very excited to be here, and my goals for you throughout this course are clear: to improve your processes for clinical reasoning, to direct your prioritization skills, and to hone in on patient safety so that you can feel adequately prepared to enter acute care from day one. I want to empower you to decrease your feelings of anxiety and imposterism and to walk away from this course with greater confidence in a setting that is uniquely challenging.

I am a licensed occupational therapist practicing in adult acute care with experience across the CVICU, ICU, telemetry, orthopedic, and medical-surgical settings. My professional focus is on supporting new and early career occupational therapy practitioners in developing self-assurance through a clear, practical approach grounded in strong clinical reasoning and decision-making. I want what I share with you today to be useful from the very first day you step onto an acute care unit.

Here is what we will cover: the challenges of transitioning into the acute care setting, imposter syndrome and how to build confidence, the guiding mottos that anchor good practice, what a typical day looks like for an acute care therapist, how to approach clinical reasoning and prioritization, common contraindications across cardiovascular, pulmonary, neurological, and orthopedic conditions, strategies for effective interdisciplinary communication, and a detailed case walkthrough that ties everything together.

Section 1: Introduction and Transition to Acute Care

Acute Care Challenges

Acute care is met with significant medical complexity, a fast pace, and high patient acuity. These are not abstract difficulties. They are the realities you will face from the moment you clock in. Discharge planning begins on day one, which means you are immediately thinking about equipment recommendations, the plan of care, patient and family goals, and the most appropriate setting for continued therapy after discharge. At the same time, you are managing your productivity expectations, including how many units and how many patients you need to see each day.

Beyond that, there are strict documentation standards to uphold, and you will be met with frequent interruptions. These can come through secure messaging, in person conversations, and interactions with colleagues across disciplines. You want to communicate in a way that not only gets your point across but genuinely informs your team about how the patient is doing. There are also the multifactorial aspects of patient care to address, and you will encounter insurance as a real barrier to your recommendations. Insurance does not just affect equipment recommendations. It shapes where you can suggest a patient goes next, whether that is a skilled nursing facility, an inpatient rehabilitation facility, home with home health therapy, or outpatient services.

One of the most significant and often underdiscussed challenges in this setting is imposter syndrome. I define it as feeling capable and competent while simultaneously feeling like a fraud. You know what you are doing, and yet something inside tells you that you do not. If you have experienced this, you are not alone.

Imposter Syndrome in Occupational Therapy

The literature on this topic is striking. A recent survey of 665 occupational therapists and students from around the world found that 83.97% reported having moderate imposter experiences (Prisco & Walsh, 2025). To put that in perspective, four out of every five people watching this presentation may be dealing with this phenomenon right now. And just because you are experiencing imposterism does not mean there is nothing you can do about it.

One of the most powerful things you can do is improve your self-efficacy. Seek out colleagues with 5, 10, 15, or 20 years of experience. Build rapport with them so you can learn about assessments they use, interventions that have been effective with their patients based on current evidence, and so you have a trusted person to bounce ideas off of. As you increase your clinical knowledge, you will begin to recognize patterns in patient presentation. That pattern recognition will help you make more effective decisions with patient safety in mind as you move through the occupational therapy process of evaluating, intervening, reassessing, and determining outcomes. Building that knowledge base is itself a form of building confidence.

The Typical Day of an Acute Care Occupational Therapy Practitioner

Understanding what your day actually looks like can go a long way toward reducing the anxiety that comes with the unknown. You start by clocking in and selecting your patient caseload. Then you conduct thorough chart reviews. Everything you do is triaged based on who needs to be seen first and what is most important in that moment. You have evaluations to complete, treatments to provide, precertifications to manage for authorizing insurance with skilled nursing facilities, and discharges to facilitate. You will also attend meetings, whether mandatory daily or every other day meetings, committee meetings, or quarterly board meetings. Effective time management is not optional here. It is a survival skill.

You also need to stay aware of any status changes happening with your patients throughout the day. A patient may have been stable in the morning and transferred to the ICU or CVICU by the afternoon. Someone may have a stroke while admitted for a different diagnosis, which may require a new order for OT evaluation if their plan of care is going to change. You are also tracking key performance indicators and meeting your institution's productivity and documentation requirements.

Guiding Mottos in Acute Care

I want you to internalize three guiding mottos that will anchor your practice in this setting:

• Safe decision-making drives acute care occupational therapy.
• Medical stability, safety, and function guide acute care decisions.
• Safety informs clinical reasoning, treatment, documentation, and communication.

These are not just phrases. They are the foundation of everything I will share with you today. When you are uncertain about what to do next, come back to these. They will point you in the right direction.

Section 2: Clinical Reasoning and Prioritization

Emphasis on Safety and Function

Everything in acute care clinical reasoning comes back to safety and function. When you receive a referral, your first task is to go back to the reason for admission and understand how that is impacting how this person is going to perform. You analyze performance skills and client factors. You think about range of motion, strength, balance, coordination, proprioception, sensation, and posture, and how each of these is affecting what this person can do by the time they leave the hospital.

You also think immediately about discharge. Will this person be going home alone or with support available? If they will have help, is that support available 24 hours a day, or is it intermittent? Who will be providing it? Consider a patient who had a hip replacement, must follow their own precautions, and has cognitive deficits. If their primary caregiver at home also recently had surgery, it may not make sense to recommend a home discharge if 24/7 care is your recommendation and it simply cannot be provided.

The Acute Care Decision-Making Approach

There is a reliable framework I use for decision-making in this setting. Start by confirming medical stability. Then conduct a risk versus benefit analysis. Monitor lab value trends, because if a patient's troponin is slowly climbing, that matters for whether you proceed with a session. Check what consults are pending. If cardiology, orthopedic surgery, or neurosurgery needs to see the patient first and will be providing recommendations that directly affect safe mobility, you may need to hold. If there is urgent imaging that has not yet been read and interpreted, you need to wait. Know the patient's precautions and weight-bearing status, because both affect safety and the entire plan of care.

Medical Stability: Vitals and Lab Values

Monitoring vitals during sessions is a fundamental part of what you do. Blood pressure is one of the most important indicators. You want to know the supine, sitting, and standing blood pressures when applicable, as a drop of 20 points systolic indicates orthostatic hypotension. If a patient has a low blood pressure, look at the mean arterial pressure, because that tells you whether the organs are being adequately perfused. If the MAP is below 65, the patient likely needs to be returned to a supine position and monitored closely.

Heart rate tells you a great deal as well. Bradycardia below 60 and tachycardia above 100 at rest both warrant attention. A resting heart rate in the 140s or 160s is typically a reason to hold the session. Respiration rate of 12 to 20 breaths per minute is the expected range. Oxygen saturation should generally be at 95% or higher. For patients with COPD, saturation between 88% and 90% can be more typical, but if you see someone dip into the low 80s or the 70s, you need to help them rest, implement breathing techniques such as pursed lip or diaphragmatic breathing, and notify nursing or respiratory therapy if the situation continues to decline. Temperature is another vital sign worth tracking, particularly in patients with hypothermia or infection.

Lab values deserve careful attention as well. Electrolytes like sodium and potassium tell you about arrhythmia and seizure risk. Calcium levels are particularly relevant for patients with bone cancer diagnoses, as hypercalcemia can make a patient significantly weaker than you might anticipate when you enter the room. Elevated ammonia may mean a patient is on lactulose, which causes frequent trips to the bathroom and can affect the flow of your session. Hemoglobin below 7 often signals an active blood transfusion, during which nursing is monitoring closely every 30 minutes for adverse reactions. White blood cell count tells you about infection status and whether neutropenic precautions are in place. Platelets inform you about clotting capacity. All of these values paint a picture that shapes how you will proceed.

Lines and Tubes

You will encounter a wide variety of lines and tubes in acute care, and knowing how to safely manage them is non-negotiable. Telemetry monitors heart rate and rhythm through five leads and electrodes on the chest. If a patient needs to mobilize beyond the reach of the cable, you switch them to a portable telemetry box, making sure the code on the box matches what is displayed on the monitor so they remain visible to nursing staff and cardiology. For oximetry, be aware that impaired circulation, Raynaud's phenomenon, or nail polish can interfere with an accurate reading at the finger. A probe placed on the toe or forehead may give better results.

For a Foley catheter, cross it over the patient's leg and position it slightly past the hip on the bed rail when mobilizing so that it does not get tangled as they rise to stand. Central lines may be located at the internal jugular, subclavian, or femoral sites. Make sure there is no flexion that could kink the line. A pulmonary artery catheter, commonly found in the CVICU after open heart surgery, runs from the right atrium to the right ventricle to the pulmonary artery. Mobilization with this line in place is typically limited to a recliner chair until it is removed. Arterial lines in the brachial or radial arteries measure continuous arterial pressure and must not be dislodged. Internal pacing wires require pacemaker precautions to prevent them from being inadvertently pulled out of the heart.

A rectal tube is managed similarly to a Foley catheter. Secure it in a location where the patient will not become tangled, using the bed rail or the walker as anchor points. Peripheral IVs are typically connected to a pole that can be moved with the patient. If a peripheral IV cannot be placed, a PICC line may be inserted for longer term access. Do not take blood pressure on the extremity where the PICC line is located. Watch also for signs of IV infiltration, such as fluid leaking and localized swelling, and notify nursing if you observe this.

Chest tubes may be placed after a pneumothorax or pleural effusion. The flexible tubing is inserted into the chest wall and drains into a canister where output is measured. Check the order to determine whether the chest tube is on water seal or suction, and ensure the tubing is not dislodged during mobility. Nasogastric tubes are secured to the patient's gown and extend into the stomach to manage nausea, vomiting, or small bowel obstruction. Endotracheal tubes indicate the patient is on a ventilator. If they are attempting to wean, they may be doing spontaneous breathing trials. Use the RASS scale to assess level of sedation and determine whether the patient is alert enough to participate in therapy. Tracheostomy tubes come with a limited range of movement to consider. Some patients will have a speaking valve allowing communication; others may need pen and paper as an alternative.

Precautions and Weight-Bearing Status

Spinal precautions mean no bending, lifting, or twisting. The patient will use a log roll technique to mobilize to the edge of the bed. C-spine precautions typically involve a hard cervical collar, with the patient restricted from neck flexion, extension, rotation, or lateral flexion. Additional bracing such as a TLSO or LSO may also be involved, and the specific instructions for donning these in a supine versus seated position depend on the brace type and physician recommendations.

After open heart surgery, sternal precautions apply. The patient will not be pushing, pulling, reaching the arms overhead, out to the side, or behind the back. A heart pillow is commonly used to brace the sternum when the patient coughs, laughs, sneezes, or hiccups, and it is genuinely effective at reducing discomfort. Pacemaker precautions are similar to sternal precautions but apply to one side.

Weight-bearing status requires careful chart review. Non-weight bearing, weight bearing as tolerated, partial weight bearing, and toe-touch weight bearing each carry different clinical implications. One thing I want to highlight about toe-touch weight bearing is that patients frequently try to put half their weight through their toes. What this status actually means is that the toes are used for balance only. When you explain it in those terms, patients tend to comply much more reliably. Always look for an operative note with recommendations and confirm there is a documented weight-bearing order before working with any post-surgical patient.

Risk Versus Benefit Analysis

The risk versus benefit analysis is something you run continuously in acute care. Ask yourself whether you need to modify the session, hold it entirely, or proceed with close monitoring. If there is a bed rest order, check whether neurosurgery has provided specific clearance for a mobility task such as standing for weight-bearing X-rays. That is a specific scenario where you would act only with direct physician authorization.

Vasoactive medications and sedatives can significantly affect blood pressure and alertness, which shapes what is safe to attempt. Physician clearance may be needed before proceeding with certain patients on these medications. If there is imaging pending that has not yet been interpreted, wait. The radiologist or physician must read and communicate the results before you safely mobilize the patient.

Research on decision-making in this setting affirms the importance of analysis over intuition alone. A 2024 scoping review of 22 articles found that while intuition can serve as a guiding force, analysis is the primary driver of good decision-making in acute care (Vermeulen et al., 2024). Intuition becomes more useful with accumulated experience, but it should never replace systematic review. A 2025 study examining OT decision-making for cognitive assessments after acute traumatic brain injury found that safety and time constraints lead therapists to favor a functional, observation-based approach, with activities modified or shortened as needed in a fast-paced environment (Goodchild et al., 2025). Tools such as the AM-PAC 6-Clicks, the Timed Up and Go, and the Five Times Sit to Stand can support real-time documentation of a patient's ADL performance and functional strength without requiring excessive time to administer.

Section 3: Safety Awareness and Contraindications

Knowing when to hold a session is just as clinically important as knowing how to treat. In acute care, red flags fall into four primary categories: cardiovascular, pulmonary, neurological, and orthopedic. When you encounter any of these, the response is the same: stop and analyze, communicate with your team, and document your findings.

Cardiovascular Red Flags

Unstable angina is a significant concern. If a patient is reporting pain radiating to the neck, jaw, arm, or back, or if they are experiencing increased shortness of breath, chest pain, pressure, or tightness that is not relieved with rest or medication, you are holding that session. Uncontrolled arrhythmias also require you to pause. Newly developed atrial fibrillation with a resting heart rate already at 140 or 160 beats per minute is a reason to hold. Ventricular fibrillation or ventricular tachycardia are the most dangerous arrhythmias and require immediate intervention from the clinical team, not a therapy session.

Deep vein thrombosis is another contraindication when anticoagulation is required. If a patient is on heparin and it has not yet reached therapeutic range, you will wait. If they have transitioned to a medication like apixaban and levels are within range, you are more likely able to proceed, but review the full picture carefully. New ECG changes typically warrant cardiology review before you engage. Worsening heart failure symptoms, which may present as increasing shortness of breath, fluid buildup in the feet, ankles, or abdomen, and rising oxygen requirements, are a signal to wait. Any emergent concern, such as a code blue or active cardiac arrest, means you are not seeing that patient.

Pulmonary Red Flags

A new, untreated pulmonary embolism, including a saddle pulmonary embolism, is an absolute hold. Active hemoptysis, whether from bronchitis, pneumonia, tuberculosis, or another cause, requires clearance before you proceed. If oxygen requirements are increasing substantially, for example from 5 liters on admission to 15 liters, hold the session. An untreated pneumothorax is a clear contraindication. A chest tube placed without X-ray confirmation of correct placement is also a contraindication, because without that confirmation you cannot rule out worsening of the pneumothorax or conversion to a tension pneumothorax with tracheal deviation. Any urgent imaging that has not yet been read and interpreted is also sufficient reason to wait regardless of the diagnosis.

Neurological Red Flags

Intracranial bleeding warrants immediate attention. A CT scan showing a significant brain bleed often results in the patient being transferred to a higher level trauma center before you would ever have the opportunity to evaluate them. With an acute or evolving stroke, continue to monitor imaging. If the CT shows no intracranial hemorrhage and no hemorrhagic conversion, you may be able to see the patient. However, if the stroke is still evolving, hold. Any active seizure activity is a reason to wait, particularly if a continuous EEG is running for 24 hours. If a patient's mental status has acutely changed from their admission baseline, notify the nurse, document your findings, and wait for a plan to be established before proceeding. New focal deficits or new onset weakness should be treated as a stroke protocol scenario until proven otherwise. A spinal cord injury pending neurosurgery recommendations always requires you to wait for that consultation and for the surgical team's plan before you engage. If surgery is scheduled, you need to know what is happening and what the resulting precautions and weight-bearing status will be before you can proceed.

Orthopedic Red Flags

A fracture without clear mobility orders is a red flag. You need documented weight-bearing status and precautions before proceeding. If a patient is scheduled for surgery, wait until after the procedure and until they have come out of anesthesia without complications before initiating evaluation. Loosening hardware, infection with instability, or wound dehiscence, meaning the wound is separating, are all reasons to hold and ensure recommendations are in place before you introduce any potential for further harm. Poor patient compliance is also clinically significant. If a patient has been told to keep a hard cervical collar on and is removing it and rotating their neck while trying to get out of bed, you are not just holding the session. You are terminating it immediately, notifying the nurse, documenting your findings, and potentially alerting neurosurgery or orthospine. The risk of spinal cord injury in that scenario is real.

When you see a red flag, the action steps are the same every time: stop and analyze, communicate, document. Safety drives every decision in this setting.

Section 4: Interdisciplinary Communication

Barriers to Communicating in Acute Care

Effective communication is one of the hardest things to develop in acute care, and imposter syndrome sits right at the center of why. As a new therapist or someone transitioning into this setting from another practice area, you will encounter hierarchy dynamics. There are people with more experience, more tenure, and in some cases higher levels of professional education in the room with you. Navigating that takes time and practice. There is also the challenge of using medical jargon correctly and confidently. In a high-stress situation, when something is happening quickly, displaying a lack of experience feels like an even bigger obstacle, which can cause therapists to avoid being assertive altogether.

Being assertive does not mean being bold or aggressive. It means advocating for your patient. It means communicating what you found, what you are recommending, and why. That is your professional responsibility, and it is one of the most valuable things you can contribute to the team.

SBAR: A Framework for Structured Communication

One tool I want you to use is the SBAR mnemonic: Situation, Background, Assessment, and Recommendation. This structured approach works across every discipline you will interact with, including nursing, case management, physicians, physical therapy, and speech-language pathology. It organizes your communication in a way that gets your point across efficiently and professionally.

Research supports the value of this kind of intentional team communication. A 2023 study examined a one-hour workshop designed to increase hospitalists' understanding of the occupational therapy role. The workshop led to a measurable increase in more appropriate OT consults afterward (Craven & Asiello, 2023). This is a meaningful finding because it demonstrates that when you take the time to communicate your role clearly to your colleagues, it changes how they interact with you and how they refer patients. Routine team communication is simply part of being an effective acute care occupational therapist, and your contribution to that communication genuinely matters.

Here is one example of how this might work in practice. A patient is admitted after an anterior cervical discectomy and fusion, and only OT is consulted because the patient was independent at prior level of function before surgery. During your evaluation, you discover balance and gait deficits that will affect discharge safety. You document your findings, communicate your concerns to the team, and recommend a physical therapy consult. That consult gets placed, PT evaluates the patient, and now together you are both working toward the most appropriate and safe discharge disposition. That is interdisciplinary collaboration working the way it should.

Documentation Examples

Documentation in acute care is both a clinical record and a legal document. What you write matters. Here are examples of how to document four common red flag scenarios.

• For a cardiovascular finding: "Pt hypotensive (76/45) in standing with symptomatic dizziness; resolved supine. Therapy evaluation limited due to significant drop in BP."
• For a pulmonary finding: "Pt desaturated (SpO2 = 83%) during functional mobility on 5L with DOE requiring return to supine, pursed lip breathing, and 5 minutes of rest before improving to 91%. Will continue to follow."
• For a neurological finding: "Pt lethargic, perseverating with acute change in mental status and STAT CT ordered. Will await imaging and further recommendations prior to initiating OT evaluation."
• For an orthopedic finding: "Pt with R proximal humerus fx scheduled for ORIF. Will follow up post-op for therapy evaluation."

These examples use SBAR principles and communicate what happened, why the session was limited or held, and what the plan is going forward. That is the information your team and your documentation need to contain.

Section 5: Case Walkthrough

Meeting Don Smith

Let me walk you through a case that brings together everything we have covered. Don Smith is a 78-year-old male with a history of COPD, congestive heart failure, hypertension, pneumonia, type 2 diabetes, coronary artery disease, and chronic kidney disease. He presents with progressive shortness of breath over the past three weeks and dyspnea on exertion compared to his baseline. At baseline, he required 2 liters of oxygen on a nasal cannula at night. Over the past 72 hours, his need has been continuous, and in the emergency department he desaturated to 67%, requiring 7 liters on admission.

He tried his home nebulizer without improvement. He tested positive for COVID-19. He was discharged to Meadow Springs, a rehabilitation facility, approximately two weeks ago due to deconditioning following a prior hospitalization. He was not compliant with his inhaler because he ran out of medication and did not feel well enough to retrieve it from the pharmacy. He describes a nonproductive cough, mild wheezing, chest tightness, and malaise. He denies hemoptysis and denies pain radiating to the jaw or upper extremities.

Functionally, he has been ambulating only from the bedside commode to the bed over the past two days using a front-wheeled walker, and he sustained two witnessed falls at home. At baseline, he is independent with most ADLs and shares IADLs with his spouse.

Prioritization

Before you see Don, you have a full caseload to triage. Here is how you think through it. Don's evaluation was received the prior day at 1:00 PM, and your 24-hour window to initiate the evaluation runs out at 1:00 PM today. A COPD exacerbation was received at 3:00 PM yesterday. You will attempt to get to that patient the same day if a history and physical note is in the chart. If therapy hours ended without a visit, you see them first thing in the morning. An unstable C5 fracture is scheduled for surgery today. You will only see this patient after surgery if there are no complications, no bed rest order, and adequate time. A patient with a cerebrovascular accident who is a candidate for TNK received the medication this morning at 5:00 AM. TNK breaks up fibrin, the mesh that holds clots together, and you typically wait 12 hours after administration. That puts your earliest window at 5:00 PM, which may fall outside of therapy business hours, meaning you would plan to see this patient first thing the next morning. A patient with chest pain and an acute large pericardial effusion needs cardiology to see them and provide recommendations before OT engages. A patient with frequent falls and hip nailing received their order two days ago with surgery completed the same day. You are likely able to see them now. A patient with a large pleural effusion and chest tube placement with X-ray confirmation received their order yesterday at 9:00 AM. As long as placement is confirmed and there is an order specifying water seal or suction, you can proceed. And finally, an ACDF C3 through C5 with a completed operative note showing no complications received yesterday at 10:30 AM. You can see this patient today, as you are within that 24-hour window.

Chart Review and Safe Decision-Making

Turning back to Don's chart. His chest X-ray shows hyperinflated lungs, cardiomegaly, and a moderate left pleural effusion, with no focal infiltrates and no pneumothorax. His CT shows no pulmonary embolism. His lower extremity ultrasound shows no deep vein thrombosis. His echo shows heart failure with reduced ejection fraction at 30%. His oxygen needs have decreased from 7 liters on admission to 5 liters. He was placed on BiPAP while sleeping but refused it the previous night.

His ABG values show a PaCO2 of 70 mmHg, a PaO2 of 68 mmHg, and a pH of 7.32, indicating a compensated respiratory acidosis. His blood pressure is 160/90 with a mean arterial pressure of approximately 113, so his organs are perfusing. His glucose is 200, consistent with his diabetes. His BNP of 350 reflects his congestive heart failure. His eGFR of 35 to 40 is consistent with chronic kidney disease. His potassium is 5.0, which is within range and does not yet rise to the level of arrhythmia concern. His hemoglobin is adequate at 12 g/dL. His BUN is elevated, consistent with his known chronic kidney disease.

The activity order is activity as tolerated. The OT order is for evaluation and treatment. There is no urgent imaging ordered. The pulmonology consult recommends up to chair three times daily, incentive spirometry, flutter valve use, and continuation of BiPAP at night. There is no plan for thoracentesis or chest tube placement. Given all of this, there are no active contraindications or red flags to therapy at this time.

Your priorities during the session are to monitor mental status closely given that Don refused the BiPAP the previous night. Rising CO2 levels can cause increasing confusion, and you want to catch any change early. Monitor vitals throughout mobility activities and watch for symptomatic shortness of breath or dizziness. Simulate the home environment as much as possible so that your evaluation reflects what he will actually be doing at discharge. Modify the activity level as needed and provide education on how to progress activity safely at home.

Communication and Documentation

You will communicate your findings through documentation in the chart. Inform the nurse of Don's mobility and ADL status, any pertinent findings, and your discharge recommendation. Include hemodynamic data such as orthostatic blood pressures and heart rates if you obtained them. These values paint a clinical picture that helps the entire team understand where the patient is in their recovery. Educate Don on what equipment he may need, what the plan of care looks like, and what his options are for continued skilled therapy. When you finish your session, perform a safe handoff with the nurse that covers where you left the patient, whether a chair alarm or call light is in place, and anything notable that happened during the visit.

Here is an example of strong documentation for this patient: "Patient demonstrates active engagement with positional, ADL, and activity-based interventions. Progress limited during session secondary to impaired activity tolerance, functional strength, balance deficits, and decreased safety awareness. Pt would benefit from continued skilled occupational therapy in inpatient setting at discharge to address energy conservation, transfer training, neuromuscular re-education, activity tolerance in context of ADLs, HEP, compensatory and adaptive techniques and fall prevention for safe return to prior level of function. Medical complexity and increased oxygen dependence further impact safety and endurance with self-care tasks, supporting need for continued skilled intervention."

This documentation tells what went well, what limited the patient's performance, what setting and interventions they need next, and why. That is exactly what skilled documentation looks like.

Discharge Recommendations

For Don, your equipment recommendations would include an extended tub bench if he has a tub-shower or a shower chair for a walk-in shower, with education on transfer technique and fall risk reduction. A hip kit would be particularly useful given his oxygen dependence. If he desaturates or becomes fatigued during lower body dressing and bathing, having adaptive tools keeps him upright and reduces the energy cost of those tasks. A raised toilet seat with handles is another valuable recommendation. When a patient has difficulty with sit to stand transitions, this piece of equipment allows them to use their triceps more on the push-up phase while reducing the recruitment demand on the quadriceps, making the transfer safer and more independent. Educate Don and his spouse on the recommended level of supervision or assistance, what the fall history tells you about his risk factors, what he can realistically progress at home, and what follow-up care is available to him. Discuss inpatient rehabilitation, extended care facilities, home health occupational therapy, and outpatient OT as options depending on what the team determines is the safest next step.

Make sure your recommendation aligns with physical therapy's recommendations. You do not want to recommend outpatient therapy while PT is recommending inpatient rehabilitation. Coordinate with case management on equipment needs and discharge disposition to ensure there is a clear and unified plan in place for Don and his family.

Imposter Syndrome and Building Professional Confidence

I want to come back to imposter syndrome now that we have been through the clinical content, because I think it is easier to address once you have a sense of what you are working toward. Exploring imposter syndrome openly with students and early career occupational therapists is one of the most effective ways to decrease feelings of anxiety and isolation. Normalizing this phenomenon matters, and research shows that feelings of imposterism decrease over years of professional experience (Prisco & Walsh, 2025). That is meaningful, but it is also not something you have to simply wait through.

Promoting confidence through intentional exposure to acute care knowledge helps mitigate imposter syndrome actively. A useful tool for tracking your growth is the OT Acute Care Self-Efficacy Scale, which focuses on confidence in acute care abilities and knowledge and allows you to track that confidence over time so you can identify specific areas for improvement (McGee & Oldenburg, 2025). I encourage you to use this tool after completing this course. Set goals for yourself, identify areas you want to develop, and return to that scale over time to see how you are progressing. Every day in acute care is a new day, and there will always be something to learn. Embracing the role of a lifelong learner in this setting is not a limitation. It is a strength.

Conclusion

Let me tie these key takeaways back to what you came here to learn.

• Prioritize safety in acute care. Every decision, every session, every note you write comes back to safety. Medical stability, function, and safety are the compass points that guide your clinical reasoning. When you are uncertain, return to those guiding mottos.
• Recognize contraindications with certainty. Across cardiovascular, pulmonary, neurological, and orthopedic presentations, you now have a foundation for knowing when to proceed, when to modify, and when to hold. That knowledge protects your patients and protects you.
• Acknowledge and manage imposter feelings to support effective clinical decision-making. Imposterism is common in this field, particularly in acute care. Naming it, building knowledge, cultivating relationships with experienced colleagues, and tracking your growth over time are all strategies that work. You are not alone in this experience, and it does get better.
• Communicate confidently within an interdisciplinary team. Your voice matters in this setting. Use SBAR. Document clearly and thoroughly. Build relationships with the nurses, physicians, PTs, SLPs, case managers, and respiratory therapists around you. Those relationships will make you a better clinician and will result in better outcomes for your patients.
• Acute care occupational therapy is challenging. It is also where some of the most meaningful, high-impact work in our profession happens. I hope this course gives you the tools and the confidence to enter it with greater clarity and assurance.

References

See additional handout.