Occupational Therapy SOAP Notes: Complete Documentation Guide
Master OT SOAP notes with this comprehensive guide. Learn AOTA-compliant documentation with real examples from acute care, pediatrics, hand therapy, and outpatient settings. Includes templates for evaluations, treatment notes, and discharge summaries that demonstrate skilled services and medical necessity.
Why Occupational Therapy Documentation Matters
Occupational therapy documentation serves as the primary communication tool for demonstrating the value and medical necessity of OT services. According to AOTA (American Occupational Therapy Association), proper documentation is essential not only for legal and regulatory compliance but also for justifying reimbursement and proving that OT interventions require skilled professional expertise.
Unlike general health documentation, OT notes must clearly demonstrate how impairments impact functional performance and occupational participation. The focus is always on what patients can and cannot do, not just what is wrong with them.
Demonstrate Medical Necessity
Justify why skilled OT services are required for this patient at this time to achieve functional goals
Ensure Reimbursement
Medicare and insurance require proof that services are skilled, reasonable, and necessary
Legal Protection
Documentation is the only evidence that services were provided and were appropriate for the patient
Interdisciplinary Communication
Share functional status and goals with physicians, PT, nursing, and other team members
Track Outcomes
Measure progress toward functional goals with objective data to demonstrate effectiveness
Support Discharge Planning
Document readiness for discharge or need for continued services at another level of care
The Golden Rule of OT Documentation
"Document function, not just impairment." Always connect clinical findings (ROM, strength, cognitive deficits) to how they impact the patient's ability to perform meaningful activities and participate in desired occupations. Insurance doesn't pay for 10 degrees of ROM—they pay for the ability to dress independently or return to work.
The OT SOAP Format Explained
SOAP notes provide a structured framework for documenting OT services. Each section has a specific purpose in telling the patient's functional story.
Subjective
Patient/caregiver reports on functional performance, ADL concerns, pain, and goals
Key Elements to Include:
Example:
Patient reports difficulty dressing due to R shoulder pain (6/10), states "I can't reach behind my back to fasten my bra." Patient goal: "Return to painting and gardening within 2 months."
Objective
Measurable data including ROM, strength, functional mobility, standardized assessments, and task performance
Key Elements to Include:
Example:
AROM R shoulder: flexion 120°, abduction 110°, ER 30° (limited by pain). Grip strength: R 18 lbs, L 45 lbs. FIM score: 4 for UB dressing, 5 for LB dressing. Patient required verbal cues for sequencing during simulated meal prep task.
Assessment
Clinical reasoning about occupational performance, progress toward goals, medical necessity, and rehabilitation potential
Key Elements to Include:
Example:
Patient demonstrates moderate deficits in UE ROM and strength limiting ADL independence, particularly UB dressing and reaching tasks. Progress is good with 15° improvement in shoulder flexion this week. Skilled OT is medically necessary to address compensatory strategies and therapeutic exercise to restore functional ROM for ADL independence. Good rehab potential given motivation and progress.
Plan
Therapeutic activities, frequency/duration, interventions, and discharge planning
Key Elements to Include:
Example:
Continue OT 3x/week for 4 weeks. Interventions: AROM/PROM exercises, functional reaching tasks, adaptive equipment training for dressing. STG: R shoulder flexion to 140° within 2 weeks. LTG: Independent UB dressing with no adaptive equipment within 4 weeks. Will coordinate with PT for strengthening.
Complete OT SOAP Note Examples
Real-world examples from different practice settings demonstrating skilled OT documentation.
Acute Care - Post-Stroke Initial Evaluation
S: Patient reports L UE "feels heavy and weak." Wife states patient was independent with all ADLs prior to stroke. Patient unable to verbalize specific goals due to mild expressive aphasia but nods agreement with goal of returning home. O: Mental Status: Alert, follows 1-2 step commands consistently. Oriented x3. Mild expressive aphasia noted. L UE: Flaccid tone, 0/5 strength throughout. No active movement. Intact light touch and pain sensation. Shoulder subluxation approx. 1 fingerbreadth. R UE: 5/5 strength, WFL AROM, intact coordination. Sitting balance: Fair - requires min A for static sitting, mod A for dynamic sitting tasks. ADL Performance: - Grooming: Mod A, uses R hand only, difficulty managing items with one hand - UB dressing: Max A, unable to don shirt over L arm - LB dressing: Max A due to sitting balance deficits - Feeding: Mod A, R hand functional but requires setup and cueing for safety FIM Scores: Eating 4, Grooming 3, UB dressing 2, LB dressing 2 A: 68 y/o male with L hemiparesis and mild aphasia post R MCA stroke demonstrates significant functional deficits in ADLs requiring moderate to maximal assistance. Impairments include absent L UE function, impaired sitting balance, and mild cognitive-linguistic deficits impacting safety awareness. Patient demonstrates good attention and follows commands, indicating fair rehabilitation potential. Skilled OT is medically necessary to establish compensatory strategies for one-handed ADL techniques, improve sitting balance for ADL safety, prevent L UE complications, and facilitate motor recovery to maximize functional independence. P: OT daily x 7-10 days then reassess. Interventions: L UE PROM to prevent contractures, shoulder positioning/subluxation management, one-handed ADL training (dressing, grooming, feeding), sitting balance activities during functional tasks, L UE facilitation techniques, cognitive retraining for safety awareness, caregiver education. STG (1 week): - Patient will complete grooming tasks with SBA using one-handed techniques - Patient will maintain sitting balance with SBA during static ADL tasks - Caregiver will demonstrate proper L UE positioning and PROM LTG (at discharge): - Patient will complete grooming with modified independence - Patient will require min A for UB/LB dressing using adaptive equipment - Patient/caregiver educated on home exercise program and safety strategies Next session: Continue one-handed ADL training, introduce adaptive equipment trial.
Pediatric Outpatient - Fine Motor/Sensory Processing
S: Mother reports "He still can't use scissors and avoids coloring or writing activities at school." States child becomes dysregulated with messy textures and refuses to participate in art activities. Teacher reports child has difficulty with pre-writing skills and manipulating small objects. Mother's goal: "I want him to be able to do the same activities as his classmates." O: Sensory Profile 2: Definite difference in tactile and vestibular processing. Seeks movement, avoids tactile input to hands. Beery VMI: Standard score 75 (well below average for age) Fine Motor Skills: - Tripod grasp: Dynamic tripod emerging but fatigues quickly, reverts to fisted grasp - Cutting: Unable to cut along a line, makes random snips - Drawing: Copies circle and cross, unable to copy square. Lines are uncontrolled with excess pressure - Manipulation: Difficulty with fasteners, buttons, zippers - In-hand manipulation: Unable to complete finger-to-palm translation Gross Motor: Decreased core stability, poor sitting posture during table tasks. W-sits during floor play. Bilateral Coordination: Difficulty with bimanual tasks; does not stabilize paper while coloring. Sensory: Tactile defensive with glue, paint, playdough. Seeks deep pressure and movement. Poor body awareness. Play/Engagement: Required frequent movement breaks. Perseverative with spinning toys. Avoided fine motor activities initially but engaged after sensory preparation. A: 5 y/o male demonstrates significant fine motor delays (>1.5 SD below mean on VMI) and sensory processing difficulties impacting pre-academic skills and classroom participation. Tactile defensiveness leads to avoidance of age-appropriate art and learning activities, limiting educational participation. Poor core stability and bilateral coordination contribute to inefficient grasp patterns and fatigue during writing tasks. Skilled OT is medically necessary to address underlying sensory processing deficits, develop age-appropriate fine motor skills for school readiness, and improve occupational engagement in pre-academic tasks. Good rehabilitation potential given age and engagement with skilled intervention. P: OT 2x/week for 12 weeks. Interventions: Sensory-based treatment including therapeutic brushing protocol, heavy work activities for regulation, graduated exposure to tactile activities, core strengthening through play-based activities, fine motor skill development (scissor skills, grasp development, in-hand manipulation), bilateral coordination activities, home sensory diet. STG (6 weeks): - Child will participate in 10 minutes of tactile play activities (playdough, finger painting) with coaching - Child will cut along a straight line with 70% accuracy - Child will demonstrate functional tripod grasp for 5 minutes during coloring tasks LTG (12 weeks): - Child will participate in classroom art activities without avoidance behaviors 80% of opportunities - Child will cut simple shapes (circle, square) with 80% accuracy - Child will demonstrate dynamic tripod grasp during 15-minute writing/coloring activities - Child will copy pre-writing shapes (square, triangle) with 80% accuracy Home Program: Sensory diet provided to mother including heavy work activities (pushing/pulling, carrying weighted items), oral motor input (crunchy/chewy snacks), proprioceptive play (crash pad, rough-housing). Daily scissor practice with supervision. Next session: Continue sensory-based activities, introduce scissor skills training using therapeutic scissors.
Hand Therapy - Distal Radius Fracture
S: Patient reports R wrist stiffness and weakness limiting ability to type, use mouse, and perform household tasks. States pain is 3/10 at rest, 6/10 with typing after 20 minutes. Patient goal: "Return to work full-time as administrative assistant and be able to do yoga again." O: Edema: Trace at wrist, no pitting AROM R wrist: Flexion 35° (L 75°), Extension 40° (L 70°), Radial deviation 10° (L 20°), Ulnar deviation 20° (L 35°) PROM R wrist: Flexion 45° (firm end feel), Extension 50° (firm end feel), mild discomfort at end range Forearm rotation: Supination 70° (L 85°), Pronation 75° (L 80°) Grip strength (Jamar): R 25 lbs (L 65 lbs, 38% of L) Pinch strength (3-jaw chuck): R 8 lbs (L 15 lbs, 53% of L) Functional Testing: - Keyboard/mouse use: Tolerated 5 minutes before reporting pain increase to 6/10 - Sustained grasp: Able to hold coffee mug but reports feeling of weakness - Fine manipulation: Able to button buttons but slower than L hand Scar: Well-healed, minimal adhesions, performs self-massage Pain: Reports sharp pain with end-range extension and flexion A: 52 y/o female 6 weeks post ORIF R distal radius fx demonstrates significant ROM limitations (approximately 50% of normal) and strength deficits (38% of uninvolved side) limiting occupational performance for work and leisure activities. PROM gains of 10° over AROM indicate potential for improvement with skilled intervention. Stiffness and weakness prevent return to full-time desk work and leisure activities (yoga). Skilled OT/CHT is medically necessary to restore functional ROM and strength through therapeutic exercise, joint mobilization, pain management, and work simulation activities to enable return to prior level of function. Excellent rehabilitation potential given fracture healing, patient motivation, and early stage of recovery. P: Hand therapy 2x/week for 6-8 weeks. Interventions: AROM/AAROM exercises, gentle joint mobilization, progressive strengthening (therapeutic putty, graded gripping activities), edema management, scar mobilization, work simulation activities (keyboard/mouse tasks with progressive duration), ergonomic education, instrument-assisted soft tissue mobilization (IASTM) as needed. STG (3 weeks): - R wrist flexion to 50°, extension to 55° - Grip strength to 35 lbs (54% of L) - Tolerate keyboard/mouse use for 30 minutes with pain ≤3/10 LTG (6-8 weeks): - R wrist ROM WNL or 80% of contralateral side - Grip strength 80% of contralateral side - Return to full-time work without restrictions - Return to modified yoga practice HEP: AROM exercises 5x/day (flexion/extension, radial/ulnar deviation, forearm rotation), self-scar massage 3x/day, progressive strengthening with therapeutic putty. Activity modification strategies for computer work. Frequency: 2x/week for 4 weeks, then reassess and taper to 1x/week. Next session: Progress PROM, initiate joint mobilization techniques, advance strengthening activities.
Outpatient - Total Knee Replacement (ADL Focus)
S: Patient reports difficulty with showering, dressing (socks, shoes), and getting in/out of car due to knee stiffness and pain (currently 4/10). States "I can't bend down to reach my feet and I'm scared I'll fall in the shower." Lives alone in single-story home. Goal: "Be independent at home so my daughter doesn't have to keep coming over every day." O: L knee ROM: Flexion 85° (limited by pain and swelling), Extension -5° (lacks full extension) Transfers: Modified independent sit-stand with bilateral UE push-off, uses proper hip precautions Standing tolerance: 5 minutes before requiring seated rest due to knee pain ADL Performance: - LB dressing: Requires 26" reacher and sock aid for donning socks/shoes; completes task with min A for balance, requires 4 minutes - Bathing: Requires tub transfer bench and long-handled sponge; SBA for safety during shower transfers; demonstrates understanding of fall prevention strategies - Toileting: Modified independent using raised toilet seat with rails - Meal prep: Modified independent at counter height, avoids tasks requiring prolonged standing Dynamic standing balance: Good with bilateral UE support, Fair without support Home safety awareness: Good - verbalizes understanding of fall risks and precautions Endurance: Fair - requires rest breaks every 10 minutes during ADL tasks A: 71 y/o female 2 weeks post L TKA demonstrates functional deficits in LB dressing and bathing requiring adaptive equipment and minimal assistance for safety. Limited knee flexion (85°) and decreased standing tolerance impact ADL independence and safety. Patient shows good safety awareness and appropriate use of adaptive equipment, indicating excellent rehabilitation potential. Skilled OT is medically necessary to progress toward modified independence in all ADLs through adaptive technique training, activity tolerance improvement, and equipment management while respecting surgical precautions and healing timeline. Patient would benefit from collaboration with PT for ROM/strengthening to support functional goals. P: OT 2x/week for 3 weeks. Interventions: ADL training with emphasis on energy conservation, proper use of adaptive equipment (reacher, sock aid, long-handled showerhead), shower transfer training to progress from SBA to modified independence, standing tolerance activities during functional tasks, coordination with PT for ROM/strengthening program. STG (1-2 weeks): - Modified independent LB dressing using adaptive equipment in <3 minutes - Modified independent shower transfers using tub bench with no loss of balance - Standing tolerance 10 minutes for meal prep tasks LTG (3 weeks): - Modified independent with all ADLs using adaptive equipment as appropriate - Demonstrate safe home mobility and ADL strategies to enable living alone safely - Patient educated on weaning from adaptive equipment as ROM improves DME Recommendations: Continue use of tub transfer bench, raised toilet seat, reacher, sock aid. Will reassess need for equipment in 4-6 weeks as ROM improves. Caregiver education: Instructed daughter on fall prevention strategies and when to provide assistance vs. allowing independence. Coordination of care: Communication with PT regarding functional ROM needs for ADL independence. Next session: Progress shower transfers toward independence, advance standing ADL activities, reassess equipment needs.
Skilled Nursing Facility - Discharge Summary
S: Patient reports feeling "much stronger and ready to go home." States he is able to take care of himself now. Wife present, expresses confidence in ability to assist patient at home with remaining deficits. Both verbalize understanding of HEP and safety strategies. O: Treatment Summary: Patient received OT 5x/week for 4 weeks focusing on ADL retraining, functional mobility, strengthening, and home safety preparation. Admission Status: - FIM scores: Grooming 4, UB dressing 3, LB dressing 2, Bathing 2, Toilet transfers 3 - Required mod A for most ADLs due to pain, limited hip ROM, deconditioning Discharge Status: - FIM scores: Grooming 7, UB dressing 7, LB dressing 6, Bathing 5, Toilet transfers 6 - All ADLs modified independent except bathing (SBA for tub transfer) - Transfers: Modified independent with front-wheeled walker, observes hip precautions consistently - UE strength: WNL bilaterally - LE dressing: Modified independent using reacher, sock aid, elastic shoelaces (2 min) - Bathing: SBA for tub transfer using tub transfer bench, modified independent with washing - Home management: Independent with light meal prep, able to retrieve items from low shelves using reacher - Safety awareness: Excellent - consistently verbalizes hip precautions, demonstrates good judgment with mobility and ADLs A: 79 y/o male post R hip fracture with ORIF has made excellent progress in OT, advancing from requiring moderate-maximal assistance with ADLs to modified independence using appropriate adaptive equipment and compensatory strategies. Patient demonstrates consistent adherence to hip precautions, safe use of walker and adaptive equipment, and good safety judgment. Has achieved functional goals for safe discharge to home with supportive spouse. Patient has reached maximum benefit from skilled OT at SNF level; will benefit from continuation of OT services via home health to address remaining bathing safety concerns and community mobility preparation. Patient education regarding progression of hip precautions and equipment weaning has been completed. Prognosis for return to prior level of independence is good given progress demonstrated. P: Patient discharged to home with wife 1/15/25. Home health OT recommended 2-3x/week for 2 weeks to progress bathing independence, assess home safety, and facilitate transition to outpatient therapy as appropriate. DME at discharge: Front-wheeled walker, raised toilet seat with arms, tub transfer bench, reacher, sock aid, long-handled shoehorn, long-handled sponge. Home Exercise Program: Reviewed and demonstrated HEP including hip ROM exercises, functional strengthening (sit-to-stand, step-ups), and daily walking program. Patient and wife verbalized understanding and demonstrated exercises correctly. Patient/Caregiver Education Completed: - Hip precautions and expected timeline (12 weeks) - Proper use of all adaptive equipment - Fall prevention strategies - Activity progression guidelines - When to call physician (increased pain, swelling, fever, loss of function) Recommendations: - Home health OT for bathing safety and home assessment - Transition to outpatient OT at 6 weeks post-op for advanced strengthening and return to prior activities (golfing, gardening) - Follow up with orthopedic surgeon at 6 weeks - Gradual weaning from adaptive equipment as ROM improves and physician clears precautions Discharge goals achieved: ✓ Modified independent with all ADLs using adaptive equipment ✓ Safe transfers with walker ✓ Consistent adherence to hip precautions ✓ Patient/caregiver educated on HEP and safety strategies ✓ Safe discharge to home environment Treatment effective. Patient discharged with good functional outcomes.
OT-Specific Documentation Terminology
Occupational therapy uses specialized terminology for assessments, functional levels, and interventions. Understanding and using these terms correctly demonstrates professional competence.
Standardized Assessments
Functional Independence Measure - 7-point scale rating ADL/mobility independence
Canadian Occupational Performance Measure - client-centered outcome measure
Assessment of Motor and Process Skills - evaluates ADL task performance
Wolf Motor Function Test - upper extremity motor ability assessment
Visual-Motor Integration test - assesses visual perception and motor coordination
Standardized sensory processing assessment for children/adults
Montreal Cognitive Assessment - cognitive screening tool
Disabilities of Arm, Shoulder, and Hand - upper extremity function questionnaire
Functional Terminology
Activities of Daily Living - basic self-care (bathing, dressing, eating, toileting)
Instrumental ADLs - complex tasks (meal prep, money management, driving)
Active Range of Motion - movement performed by patient without assistance
Passive Range of Motion - movement performed with external force
Active-Assisted Range of Motion - patient initiates, therapist assists
Manual Muscle Testing - 0-5 scale for strength assessment
Upper Extremity
Lower Extremity
Assistance Levels
No assistance required, safe, timely
Independent with equipment or extra time, safe
Stand-By Assistance - supervision for safety only, no physical contact
Contact Guard Assistance - hands-on contact for safety, no physical assistance
Minimal Assistance - patient performs 75% of task
Moderate Assistance - patient performs 50-74% of task
Maximal Assistance - patient performs 25-49% of task
Total Assistance - patient performs <25% of task
Clinical Observations
Within Normal Limits
Within Functional Limits
Bilateral
Upper Body
Lower Body
Verbal Cues
Physical Cues
Home Exercise Program
Durable Medical Equipment
Understanding Assistance Levels (FIM Scale)
The FIM scale is critical for OT documentation as it provides objective measurement of functional independence:
7 - Independent: Complete independence, safe, timely
6 - Modified Independent: Uses equipment or takes extra time, but safe and independent
5 - Supervision/Setup: Requires cueing, setup, or standby assistance for safety
4 - Minimal Assistance: Patient performs 75%+ of task
3 - Moderate Assistance: Patient performs 50-74% of task
2 - Maximal Assistance: Patient performs 25-49% of task
1 - Total Assistance: Patient performs less than 25% of task
Documenting Skilled Services and Medical Necessity
The most critical aspect of OT documentation is demonstrating that services require the skills of an occupational therapist and are medically necessary. Here's how to do it effectively.
Justifying Medical Necessity
Medicare and insurance require proof that OT services are "skilled" and medically necessary. Documentation must demonstrate this.
Key Strategies:
- Identify specific functional deficits that require skilled intervention
- Explain why the service requires OT expertise (not just supervision or repetition)
- Document complexity of task, clinical judgment required, or need for professional assessment
- Show progress toward functional goals or prevention of decline
- Link interventions to functional outcomes, not just impairments
Weak (Not Skilled):
Patient performed exercises for 30 minutes. Tolerated well.
Strong (Skilled):
Skilled instruction provided for compensatory one-handed dressing techniques including adaptive equipment training (button hook, reacher). Patient required skilled cuing to problem-solve donning shirt over affected arm. Technique modifications needed based on clinical assessment of R shoulder subluxation risk. Patient advanced from max A to mod A this session, demonstrating potential for continued functional gains with skilled intervention.
Weak (Not Skilled):
Continued working on ADLs. Patient improving.
Strong (Skilled):
Therapeutic ADL training provided addressing bilateral coordination deficits during meal prep tasks. Skilled grading of activity complexity required based on real-time assessment of cognitive load and safety awareness. Patient demonstrated improved sequencing with implementation of external visual cues (checklist), a skilled compensatory strategy requiring OT expertise to develop and modify based on patient response. This skilled intervention is medically necessary to enable safe IADL performance and reduce caregiver burden.
Documenting Progress
Show measurable changes in function, not just impairments. Connect improvements to patient goals and occupational performance.
Key Strategies:
- Use objective measurements (ROM degrees, strength pounds, FIM scores, timed tasks)
- Compare to previous session or baseline
- Describe functional implications of measured changes
- Reference established goals and progress toward achievement
- Document both progress and areas still requiring skilled intervention
Measurement:
ROM gains
Documentation:
R shoulder flexion improved from 110° to 125° over 2 weeks (goal: 140°). This 15° gain enables patient to now retrieve items from overhead kitchen cabinet (mid-level only; top shelf still requires assist), directly addressing stated goal of independent meal prep.
Measurement:
Functional task
Documentation:
LB dressing time decreased from 8 minutes with mod A to 4 minutes with min A using adaptive equipment. Patient now requires assistance only with sock donning, representing advancement of 1 FIM level and decreased caregiver burden by approximately 10 minutes daily.
Measurement:
Activity tolerance
Documentation:
Sitting tolerance during fine motor tasks increased from 5 minutes to 15 minutes over 3 weeks. Patient now able to complete classroom handwriting assignments (10-12 minutes) without movement breaks, enabling age-appropriate educational participation.
Avoiding Non-Skilled Documentation
Certain phrases or approaches suggest routine care that doesn't require OT expertise. Avoid these patterns.
Avoid These Non-Skilled Phrases:
Make It Skilled Instead:
Instead of: "Patient tolerated treatment well"
Write: Patient demonstrated improved tolerance to sensory-based activities, requiring skilled grading of tactile input to prevent dysregulation. Clinical judgment applied to adjust activity intensity based on real-time observation of arousal level and behavioral cues.
Instead of: "Supervised patient during ADLs"
Write: Provided skilled training in energy conservation techniques during morning ADL routine. Analyzed task performance to identify fatigue triggers and taught compensatory pacing strategies. Patient demonstrated improved application of techniques with decreased rest breaks needed (from 3 to 1 break during dressing routine).
Instead of: "Continues to work on dressing"
Write: Advanced dressing training from simple garments to complex fasteners (bra hooks, small buttons) requiring skilled grading based on fine motor capability assessment. Introduced new adaptive strategy (buttonhook technique) requiring demonstration, cueing, and feedback to develop motor learning.
Common OT Documentation Mistakes to Avoid
These frequent errors can result in denied claims, audit flags, and questions about medical necessity.
Focusing on impairments instead of functional deficits
Avoid:
Patient has decreased ROM and weakness.
Better:
Patient demonstrates R shoulder ROM limitations (flexion 120°, abduction 110°) and reduced grip strength (25 lbs, 40% of L) resulting in inability to independently don overhead garments or retrieve items from kitchen cabinets, limiting ADL and IADL independence.
Why it matters: Insurance pays for improved function and participation, not just impairment resolution. Always connect impairments to how they impact occupational performance.
Vague or non-specific interventions
Avoid:
Patient participated in therapeutic activities.
Better:
Patient engaged in graded reaching activities using graduated cones placed at shoulder, eye, and overhead heights to address functional reaching deficits for ADL tasks. Activity progressed from supported sitting to standing as sitting balance improved, demonstrating skilled clinical decision-making.
Why it matters: Specific interventions demonstrate skilled care and allow other team members to understand your treatment approach.
Not justifying skilled services
Avoid:
Patient practiced buttoning buttons for 20 minutes.
Better:
Skilled fine motor training provided for button management requiring therapeutic grading of button sizes, skilled cueing for compensatory pincer strategies to accommodate thumb CMC arthritis, and real-time assessment of pain impact on functional performance. Patient technique modifications required OT expertise to prevent pain flare while building skill.
Why it matters: Without skilled justification, the service could be interpreted as supervised practice that doesn't require professional expertise.
Lack of measurable data
Avoid:
Patient improved with dressing this week.
Better:
Patient advanced from mod A to min A for LB dressing, completing task in 6 minutes (previously 10 minutes). Requires assistance only with sock donning. FIM score improved from 4 to 5, indicating functional progress toward independence goal.
Why it matters: Measurable data provides objective evidence of skilled service effectiveness and progress toward goals.
Copy-paste documentation without updates
Avoid:
Using identical objective data and assessment from previous notes without modification.
Better:
Document current session findings based on actual observation. Note comparisons to previous sessions: "R shoulder flexion 130° (improved from 120° last week)."
Why it matters: Copy-paste documentation is fraudulent if it doesn't reflect actual care provided. It also fails to capture patient changes, potentially delaying necessary care modifications.
Forgetting to document medical necessity
Avoid:
Ending note without explaining why OT is still needed.
Better:
Skilled OT remains medically necessary to progress compensatory strategies for ADL independence, address ongoing safety concerns with bathing transfers, and advance strength/ROM for functional reaching tasks. Patient demonstrating consistent progress indicating good rehabilitation potential.
Why it matters: Each note should justify continued need for skilled services. If you can't justify it, patient may be ready for discharge or HEP only.
Not addressing barriers to progress
Avoid:
Ignoring factors impacting patient performance (pain, fatigue, motivation).
Better:
Patient performance limited today by increased pain (7/10 vs. typical 4/10), resulting in decreased ROM (flexion 115° vs. 125° last session) and early fatigue during functional tasks. Pain management strategies discussed; will coordinate with physician regarding medication timing before therapy sessions.
Why it matters: Documenting barriers demonstrates clinical reasoning and proactive problem-solving, both skilled services.
Inadequate discharge planning documentation
Avoid:
Patient discharged. Goals met.
Better:
Patient achieved goal of modified independence with all ADLs using appropriate adaptive equipment (reacher, sock aid, raised toilet seat). Patient and caregiver educated on HEP for continued ROM/strengthening, equipment care, and fall prevention strategies. Verbalized understanding and demonstrated techniques correctly. Recommended follow-up with outpatient OT in 4-6 weeks if functional deficits persist after equipment weaning. Discharge appropriate at this time.
Why it matters: Thorough discharge documentation demonstrates completion of skilled care, patient readiness, and appropriate transitions.
OT Documentation Templates
Use these templates as starting points for your OT documentation. Customize based on setting, patient population, and facility requirements.
Initial Evaluation Template
OCCUPATIONAL THERAPY INITIAL EVALUATION Date: ____________ Time: ____________ Setting: ____________ Patient: ___________ DOB: _______ MRN: _______ Diagnosis: __________ SUBJECTIVE Patient/Caregiver Report: Chief complaint/functional concerns: _________________________________ Prior level of function: ____________________________________________ Patient goals: _____________________________________________________ Relevant medical history: ___________________________________________ Living situation: __________________________________________________ Support system: ____________________________________________________ OBJECTIVE Mental Status: Alert [ ] Oriented x___ [ ] Follows ___-step commands Communication: WNL [ ] Impaired [ ] - describe: ____________________ Vision/Hearing: WNL [ ] Impaired [ ] - describe: ___________________ UE Active ROM: (note L/R and degrees) Shoulder: Flexion ___ Abduction ___ ER ___ IR ___ Elbow: Flexion ___ Extension ___ Forearm: Supination ___ Pronation ___ Wrist: Flexion ___ Extension ___ RD ___ UD ___ Strength (MMT 0-5): R UE: ___ L UE: ___ R LE: ___ L LE: ___ Sensation: Intact [ ] Impaired [ ] - describe: ____________________ Coordination: WNL [ ] Impaired [ ] - describe: ____________________ Balance: Sitting: _______ Standing: _______ Standardized Assessments: FIM Scores: Eating___ Grooming___ UB Dressing___ LB Dressing___ Bathing___ Toileting___ Other: ___________________________________________________________ ADL Performance: Grooming: _____ [ ] Ind [ ] Mod I [ ] SBA [ ] Min A [ ] Mod A [ ] Max A UB Dressing: _____ [ ] Ind [ ] Mod I [ ] SBA [ ] Min A [ ] Mod A [ ] Max A LB Dressing: _____ [ ] Ind [ ] Mod I [ ] SBA [ ] Min A [ ] Mod A [ ] Max A Bathing: _____ [ ] Ind [ ] Mod I [ ] SBA [ ] Min A [ ] Mod A [ ] Max A Feeding: _____ [ ] Ind [ ] Mod I [ ] SBA [ ] Min A [ ] Mod A [ ] Max A IADL Performance (as applicable): Meal prep: _________________________________________________________ Home management: ___________________________________________________ Other: ____________________________________________________________ ASSESSMENT Summary of functional deficits and impact on occupational performance: _____________________________________________________________________ Factors affecting performance: _____________________________________________________________________ Rehabilitation potential: [ ] Excellent [ ] Good [ ] Fair [ ] Poor Justification for skilled OT: _____________________________________________________________________ Medical necessity statement: _____________________________________________________________________ PLAN Frequency/Duration: OT ___x/week for ___ weeks Interventions: _____________________________________________________________________ Short-term goals (___weeks): 1. ________________________________________________________________ 2. ________________________________________________________________ 3. ________________________________________________________________ Long-term goals (___weeks): 1. ________________________________________________________________ 2. ________________________________________________________________ 3. ________________________________________________________________ DME recommendations: _____________________________________________________________________ Coordination with other disciplines: _____________________________________________________________________ _________________________________ ____________ OTR/L Signature Date
Treatment Note Template
OCCUPATIONAL THERAPY TREATMENT NOTE
Date: ____________ Time: ____________ Session: ___ of ___
S: Patient reports: _______________________________________________
Pain level: ___/10 Location: ___________
Functional concerns: _________________________________________
O: Interventions provided:
[ ] Therapeutic exercise (specify): ____________________________
[ ] Therapeutic activities (specify): __________________________
[ ] ADL training (specify): _____________________________________
[ ] Adaptive equipment training: ________________________________
[ ] Cognitive retraining: _______________________________________
[ ] Sensory integration: ________________________________________
[ ] Other: ____________________________________________________
Current measurements:
ROM: _________________________________________________________
Strength: ____________________________________________________
Functional performance: _______________________________________
Patient response/tolerance:
_______________________________________________________________
A: Progress toward goals: [ ] Progressing [ ] Plateau [ ] Regressing
Comparison to last session: ____________________________________
Factors impacting performance: _________________________________
Skilled OT is medically necessary because: ____________________
_______________________________________________________________
Rehabilitation potential: [ ] Good [ ] Fair [ ] Guarded
P: Continue OT at current frequency [ ] Modify to: _______________
Next session plan: _____________________________________________
Modifications to treatment plan: _______________________________
Patient/caregiver education provided: __________________________
HEP updated: [ ] Yes [ ] No
_________________________________ ____________
OTR/L Signature DateSave Time on OT Documentation with AI
PatientNotes helps occupational therapists document faster while maintaining AOTA compliance and demonstrating skilled services. Generate structured SOAP notes from brief dictation, automatically calculate FIM scores, and ensure medical necessity is clearly documented.
Try PatientNotes FreeFrequently Asked Questions
What is the SOAP format for occupational therapy documentation?
SOAP stands for Subjective, Objective, Assessment, and Plan. In OT, Subjective includes patient/caregiver reports on functional performance and ADL concerns. Objective contains measurable data like ROM, strength, FIM scores, and functional task performance. Assessment analyzes occupational performance, progress, and medical necessity. Plan outlines therapeutic activities, frequency, goals, and equipment recommendations.
How do I justify medical necessity in OT documentation?
To justify medical necessity, document specific functional deficits requiring skilled OT intervention, explain why the service requires OT expertise (not just supervision), demonstrate complexity requiring clinical judgment, show measurable progress or prevention of decline, and link interventions directly to functional outcomes. Always connect impairments to how they impact occupational performance and participation.
What is the difference between FIM levels in OT documentation?
FIM (Functional Independence Measure) uses a 7-point scale: 7=Independent, 6=Modified Independent (with equipment/extra time), 5=Supervision/Setup, 4=Minimal Assistance (patient does 75%), 3=Moderate Assistance (patient does 50-74%), 2=Maximal Assistance (patient does 25-49%), 1=Total Assistance (patient does <25%). These levels provide objective measurement of ADL independence.
How often should OTs document?
Documentation frequency depends on setting and payer requirements. Acute care typically requires daily notes. SNF requires weekly progress notes and at each certification/recertification. Outpatient requires notes each visit. Initial evaluations, progress notes (weekly to monthly depending on setting), re-evaluations, and discharge summaries are standard across settings. Always document when there are significant changes in patient status.
What assessments should OTs document for skilled services?
OTs should document standardized assessments like FIM scores, ROM measurements (AROM/PROM), manual muscle testing (MMT), functional task performance with assistance levels, cognitive/perceptual assessments (MoCA, AMPS), sensory processing observations (Sensory Profile), hand function tests (grip/pinch strength), and occupation-specific assessments like COPM (Canadian Occupational Performance Measure). Use objective, measurable data whenever possible.
How do I write ADL goals for OT documentation?
ADL goals should be SMART: Specific (name the exact ADL task), Measurable (include FIM level or time), Achievable (realistic for patient), Relevant (meaningful to patient), and Time-bound (specific timeframe). Example: "Patient will complete LB dressing with modified independence using adaptive equipment (reacher, sock aid) in 5 minutes or less within 3 weeks." Always focus on functional outcomes, not just impairment reduction.
What is the difference between skilled and non-skilled OT services?
Skilled services require OT expertise, clinical judgment, and professional knowledge to safely and effectively achieve functional outcomes. Examples: analyzing task performance to develop compensatory strategies, therapeutic grading of activities, complex assessment requiring professional interpretation, patient education requiring behavior change strategies. Non-skilled services are routine, repetitive, or could be safely performed by non-professionals with basic training, such as simple supervision during routine ADLs without teaching or modification.
What should be included in an OT discharge note?
OT discharge notes should include: summary of treatment provided and duration, comparison of admission vs. discharge functional status (with FIM scores or other measures), goals achieved vs. not achieved with explanation, current ADL/IADL status, equipment provided and training completed, home exercise program and patient/caregiver education provided with demonstration of understanding, discharge disposition, recommendations for continued care or follow-up, and reason discharge is appropriate at this time.
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