Occupational Therapy NotesSOAP Note Templates & Examples
Complete guide to OT documentation including SOAP notes, initial evaluations, progress notes, and discharge summaries. With real examples, templates, and Medicare documentation requirements.
What Makes Good OT Documentation?
Occupational therapy documentation must demonstrate skilled care, medical necessity, and progress toward functional goals. Whether you're documenting an initial evaluation, daily treatment note, or discharge summary, your notes should clearly show how OT services improve the patient's ability to perform meaningful activities of daily living.
The SOAP format (Subjective, Objective, Assessment, Plan) is the most common structure for OT treatment notes. This format organizes information logically, making it easy for other healthcare providers to understand the patient's status and your clinical reasoning.
AI documentation tools like PatientNotes can help OTs reduce documentation time by 50% or more, allowing you to focus on patient care while maintaining compliant, thorough documentation.
Assistance Level Terminology
Use consistent terminology to document patient assistance levels. This standardized language ensures clear communication across providers.
| Level | Abbreviation | Description |
|---|---|---|
| Dependent | Dep | Patient cannot participate; 100% assistance required |
| Maximum Assistance | Max A | Patient performs 25% of task; 75% assistance needed |
| Moderate Assistance | Mod A | Patient performs 50% of task; 50% assistance needed |
| Minimum Assistance | Min A | Patient performs 75% of task; 25% assistance needed |
| Contact Guard | CG | Hands-on for safety only; no physical assist |
| Stand-by Assistance | SBA | Therapist within arm's reach for safety |
| Supervision | Sup | Requires oversight; may need verbal cues |
| Modified Independent | Mod I | Independent with equipment or extra time |
| Independent | I | No assistance or equipment needed |
OT Documentation Templates
Use these comprehensive templates for all types of occupational therapy documentation. Each includes required elements and real-world examples.
Initial Evaluation Note
Comprehensive assessment establishing baseline function and treatment plan.
Required Elements:
Example:
OCCUPATIONAL THERAPY INITIAL EVALUATION Date: 12/18/2024 Therapist: Sarah Johnson, OTR/L PATIENT INFORMATION: Name: Robert Smith DOB: 05/22/1958 Diagnosis: S/P R CVA with L hemiparesis (I63.9) Referral: Dr. Martinez, Neurology Date of Onset: 11/20/2024 OCCUPATIONAL PROFILE: Prior Level of Function: Independent in all ADLs and IADLs. Retired accountant, lives with spouse in two-story home. Hobbies include woodworking and gardening. Current Living Situation: Lives with spouse who is able to provide supervision and minimal assistance. First floor bedroom set up temporarily. Patient Goals: "I want to be able to dress myself and use my left hand again." ASSESSMENT FINDINGS: Upper Extremity Status: - L shoulder AROM: Flexion 45°, Abduction 30° (gravity eliminated) - L elbow AROM: Flexion 90°, Extension -20° - L wrist/hand: Minimal active movement, 1/5 grip strength - Sensation: Diminished light touch L UE, impaired proprioception - Edema: Moderate dorsal hand edema Cognition/Perception: - MMSE: 26/30 (orientation -1, delayed recall -3) - L neglect: Mild, addressed with cuing - Safety awareness: Impaired - requires supervision ADL Status: - Bathing: Max A for LB, Mod A for UB - Dressing: Max A for LB, Mod A for UB - Grooming: Mod A (one-handed techniques) - Feeding: Min A (adaptive equipment needed) - Toileting: Mod A IADL Status: - Meal prep: Max A - Medication management: Mod A (cognition) - Home management: Dependent STANDARDIZED ASSESSMENTS: - Barthel Index: 45/100 - FIM: 62/126 - Box & Block (R hand): 52 blocks/min (WNL) CLINICAL IMPRESSION: 66 y/o male S/P R CVA presents with L hemiparesis, mild cognitive deficits, and decreased independence in ADLs. Patient motivated and has good family support. Fair rehab potential. GOALS (8 weeks): STG (4 weeks): 1. Patient will complete UB dressing with Min A using adaptive techniques in 15 min 2. Patient will demonstrate L shoulder AROM to 90° flexion 3. Patient will complete grooming tasks with supervision using one-handed techniques 4. Patient will demonstrate safety awareness for transfers with verbal cues only LTG (8 weeks): 1. Patient will complete all ADLs with supervision using adaptive equipment 2. Patient will demonstrate functional L UE use for stabilization during bilateral tasks 3. Patient will demonstrate consistent safety awareness without cues PLAN: Frequency: 3x/week for 8 weeks (24 visits) Interventions: - Neurodevelopmental treatment for L UE - ADL retraining with adaptive techniques/equipment - Cognitive rehabilitation - Caregiver training Medical Necessity: Skilled OT required to restore function following CVA. Patient unable to safely perform ADLs independently. Potential to improve with intensive rehabilitation. Patient/family in agreement with plan. Spouse present for education. _____________________________ Sarah Johnson, OTR/L License #: OT12345
Daily Treatment Note (SOAP)
Session documentation for each treatment visit.
Required Elements:
Example:
OCCUPATIONAL THERAPY TREATMENT NOTE Date: 12/18/2024 | Time: 10:00 AM | Duration: 45 min Therapist: Sarah Johnson, OTR/L Patient: Robert Smith | DOB: 05/22/1958 Dx: S/P R CVA with L hemiparesis | Visit: 6 of 24 SUBJECTIVE: Patient reports, "My left arm feels a little looser today." States he was able to assist with putting on his shirt this morning with wife's help. Denies pain. Sleeping well. Motivated to continue therapy. OBJECTIVE: Interventions Provided: • Neuromuscular re-education L UE (15 min) - 97112 - Weight-bearing through L UE in quadruped - Facilitation of shoulder flexion with PNF patterns - Active-assisted reaching activities at table height • Therapeutic activities (15 min) - 97530 - Bilateral sanding activity for L UE integration - Stacking cones with L hand stabilization - Pegboard activities for fine motor • ADL training (15 min) - 97535 - UB dressing practice with button hook and reacher - Grooming at sink (brushing teeth, washing face) - One-handed techniques reinforced Measurements: - L shoulder AROM: Flexion 65° (↑ from 45° eval), Abduction 45° (↑ from 30°) - L grip strength: 8 lbs (↑ from 5 lbs eval) - Dressing UB: Mod A → Min A (↑) - Grooming: Mod A → Supervision with setup (↑) Patient Performance: - Followed 3-step commands with 1 repetition - Required 2 verbal cues for L neglect - Demonstrated improved motor planning for dressing sequence - Fatigue noted after 30 min; paced activities appropriately ASSESSMENT: Patient making good progress toward STGs. L UE AROM improving with consistent treatment. ADL independence increasing with use of adaptive equipment and techniques. Cognition remains mildly impaired but improving with structure. Continue current POC. Progress Toward Goals: STG 1 (UB dressing Min A): Progressing - now at Min A STG 2 (L shoulder 90° flexion): Progressing - at 65° STG 3 (Grooming with supervision): MET - achieving with setup STG 4 (Safety awareness verbal cues): Progressing PLAN: Continue OT 3x/week per POC Next session focus: - Progress L UE strengthening - Introduce L hand in feeding tasks - LB dressing training - Caregiver training for home program _____________________________ Sarah Johnson, OTR/L
Progress Note / Re-evaluation
Periodic assessment summarizing progress and updating goals.
Required Elements:
Example:
OCCUPATIONAL THERAPY PROGRESS NOTE / RE-EVALUATION Date: 01/15/2025 Therapist: Sarah Johnson, OTR/L Patient: Robert Smith | DOB: 05/22/1958 Dx: S/P R CVA with L hemiparesis Treatment Period: 12/04/2024 - 01/15/2025 Visits Completed: 12 of 24 TREATMENT SUMMARY: Patient has attended 12 of 12 scheduled sessions (100% attendance). Treatment has focused on L UE neuromuscular re-education, ADL retraining with adaptive equipment, cognitive rehabilitation, and caregiver training. PROGRESS TOWARD GOALS: | Goal | Baseline | Current | Status | |------|----------|---------|--------| | STG 1: UB dressing Min A | Max A | Supervision | MET | | STG 2: L shoulder 90° flexion | 45° | 95° | MET | | STG 3: Grooming supervision | Mod A | Independent w/ setup | MET | | STG 4: Safety verbal cues only | Max verbal/tactile | Min verbal | Progressing | CURRENT FUNCTIONAL STATUS: Upper Extremity: - L shoulder AROM: Flexion 95° (↑50°), Abduction 75° (↑45°) - L elbow AROM: Flexion 120° (WFL), Extension -10° (↑10°) - L wrist: Active extension 15°, flexion 25° - L grip: 18 lbs (↑13 lbs from baseline) - Edema: Resolved ADL Status: - Bathing: Mod A for LB, Supervision for UB (↑) - Dressing: Mod A for LB, Supervision for UB (↑) - Grooming: Independent with setup (↑) - Feeding: Independent with adaptive equipment (↑) - Toileting: Min A (↑) Cognition: - MMSE: 28/30 (↑2 points) - L neglect: Resolving, rare cues needed - Safety awareness: Improved, min verbal cues STANDARDIZED ASSESSMENTS: - Barthel Index: 70/100 (↑25 from eval) - FIM: 89/126 (↑27 from eval) CLINICAL IMPRESSION: Patient demonstrating excellent progress in all areas. L UE motor recovery progressing well, now able to use L hand as functional assist. ADL independence significantly improved. Cognition and safety awareness continuing to improve. Patient remains motivated and engaged. REVISED GOALS (4 weeks): STG (2 weeks): 1. Patient will complete LB dressing with Min A using adaptive equipment 2. Patient will demonstrate functional L hand use for stabilization in 3/5 feeding tasks 3. Patient will complete tub transfer with Min A 4. Patient will manage morning medication routine with supervision LTG (4 weeks): 1. Patient will complete all ADLs with supervision or less 2. Patient will demonstrate safe, supervised home mobility 3. Patient will complete light meal preparation with supervision PLAN: Continue OT 3x/week for 4 weeks (12 additional visits) Total authorized: 24 visits | Remaining: 12 visits Focus areas: - LB dressing and bathing independence - Kitchen safety and meal preparation - Home modification recommendations - Driving evaluation referral consideration - Caregiver training for home program Medical Necessity: Continued skilled OT required. Patient showing excellent progress but not yet safe for independent ADLs. Potential for further improvement with continued rehabilitation. _____________________________ Sarah Johnson, OTR/L
Discharge Summary
Final documentation upon completion or discontinuation of OT services.
Required Elements:
Example:
OCCUPATIONAL THERAPY DISCHARGE SUMMARY Date: 02/12/2025 Therapist: Sarah Johnson, OTR/L Patient: Robert Smith | DOB: 05/22/1958 Dx: S/P R CVA with L hemiparesis Treatment Period: 12/04/2024 - 02/12/2025 Total Visits: 24 REASON FOR DISCHARGE: Goals met. Patient achieved independence/supervision level for ADLs as appropriate for home discharge. TREATMENT SUMMARY: Patient received skilled OT 3x/week for 8 weeks focusing on: - L UE neuromuscular re-education and strengthening - ADL retraining with adaptive techniques and equipment - Cognitive rehabilitation - Home safety and modification recommendations - Caregiver training GOAL OUTCOMES: | Goal | Baseline | Discharge | Status | |------|----------|-----------|--------| | All ADLs supervision or less | Max-Mod A | Supervision | MET | | Functional L UE for stabilization | Minimal use | Functional assist | MET | | Safe home mobility | Unsafe | Supervision | MET | | Light meal prep supervision | Max A | Supervision | MET | DISCHARGE FUNCTIONAL STATUS: Upper Extremity: - L shoulder AROM: Flexion 110°, Abduction 95° - L grip: 28 lbs - Functional use: Stabilization and light grasp ADL Status at Discharge: - Bathing: Supervision with tub bench - Dressing: Supervision (uses button hook, sock aid) - Grooming: Independent with setup - Feeding: Independent - Toileting: Supervision with grab bars - Transfers: Supervision IADL Status: - Light meal prep: Supervision - Medication management: Independent with pill organizer - Light housekeeping: Supervision Standardized Outcomes: - Barthel Index: 90/100 (baseline 45) - FIM: 108/126 (baseline 62) HOME PROGRAM PROVIDED: Written and verbal home exercise program reviewed with patient and spouse: 1. L UE stretching and strengthening exercises (daily) 2. Fine motor activities (daily) 3. Continued use of adaptive equipment 4. Energy conservation techniques 5. Fall prevention strategies ADAPTIVE EQUIPMENT ISSUED/RECOMMENDED: - Long-handled reacher - Button hook - Sock aid - Tub bench (patient purchased) - Grab bars (installed) RECOMMENDATIONS: 1. Continue home exercise program daily 2. Outpatient OT may be beneficial in 3-6 months if plateaus occur 3. Driving evaluation recommended in 3 months 4. Consider community reintegration program 5. Follow up with neurology as scheduled DISCHARGE DISPOSITION: Discharged to home with spouse supervision. Patient and family demonstrate understanding of home program and safety precautions. Emergency contact information provided. _____________________________ Sarah Johnson, OTR/L License #: OT12345
OT Documentation Best Practices
Follow these guidelines to ensure your documentation supports reimbursement and demonstrates the value of occupational therapy.
Focus on Function
Always tie interventions to functional outcomes. Document how the activity improves ADL performance, not just the exercise itself.
Demonstrate Skilled Care
Document why skilled OT services are necessary. Describe the clinical reasoning and specialized techniques used.
Use Measurable Outcomes
Include objective measurements: ROM in degrees, strength grades, assistance levels (Max A, Mod A, Min A, Supervision, Independent).
Document Patient Response
Record how the patient responded to treatment, including participation level, tolerance, and any barriers encountered.
Link to Goals
Every treatment note should reference progress toward established goals. This justifies ongoing medical necessity.
Include Education
Document all patient/caregiver education provided, including comprehension and ability to demonstrate techniques.
Medicare OT Documentation Requirements
Required Elements for Medicare Compliance
Every Treatment Note Must Include:
- Date and duration of treatment
- Specific interventions provided
- Patient response to treatment
- Progress toward goals
- Plan for next session
- Therapist signature and credentials
Medical Necessity Documentation:
- Why skilled OT (vs unskilled) is required
- Complexity of patient's condition
- Specialized OT techniques used
- Rehab potential and prognosis
- Functional outcome expectations
- Safety concerns requiring OT
Frequently Asked Questions
What is an occupational therapy SOAP note?
An OT SOAP note is a structured documentation format using Subjective (patient report), Objective (measurements and observations), Assessment (clinical analysis), and Plan (treatment plan) sections to record therapy sessions and patient progress.
How long should an OT treatment note take to write?
A well-written OT note should take 5-10 minutes. Using templates, standardized language, and AI documentation tools like PatientNotes can reduce this time significantly while maintaining quality and compliance.
What must be included in OT documentation for Medicare?
Medicare requires: skilled intervention documentation, functional outcome measures, progress toward goals, medical necessity justification, patient participation level, and plan for continued treatment or discharge.
What is the difference between OT notes and PT notes?
OT notes focus on activities of daily living (ADLs), fine motor skills, cognitive rehabilitation, and upper extremity function. PT notes focus on gross motor function, mobility, gait, balance, and lower extremity rehabilitation.
Can OT assistants (OTAs) write treatment notes?
Yes, OTAs can document treatment sessions they provide. However, evaluations and re-evaluations must be completed by a licensed OT. OTA notes should indicate supervision by the OT as required by state regulations.
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