OCCUPATIONAL THERAPY PROGRESS NOTE 2025

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An occupational therapy progress note template is a document used by occupational therapists and physical therapists to track patient progress during treatment. Categories. Healthcare Forms. Report Forms.
Writing Effective Therapy Notes Write clear, easy-to-understandable notes. Unlike progress notes, therapy notes are not meant to be shared with other care providers. Be selective, clear, and concise. Familiarize yourself with the HIPAA requirements. Ensure data security. Use simple note-taking templates. How to Write Therapy Notes (With Examples) - Mentalyc mentalyc.com blog therapy-notes mentalyc.com blog therapy-notes
Summarize the Therapy Goals and Outcomes: Clearly state what the therapy aimed to address and the progress made towards these goals. Detail the Treatment Provided: Include types of interventions used and their frequency, highlighting any adaptations made to meet specific needs.
DOs and DONTs of Writing Occupational Therapy Documentation DO use the subjective part of the note to open your story. DONT go overboard with unnecessary details. DO go into detail about your observations and interventions. DO show clinical reasoning and expertise. DONT skimp on the assessment section. DONT get lazy.
Progress notes need to address the clients treatment goals and objectives. The clients goals directly relate to their diagnosis, and their objectives are the smaller, measurable steps they have to take to docHub their goals. Include how your interventions will help the client progress toward goals.
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Occupational therapy documentation provides a record of the practitioners ac- tivity in the areas of screening, evaluation and reevaluation, intervention, and outcomes (AOTA, 2014b) in ance with practice guidelines and payer, facility, and state and federal guidelines and requirements.
An important part of an Occupational Therapy report is clear and actionable recommendations. A recommendation section should be on the summary page (first 1-2 pages of the report) or at the very end. In the recommendation section, each recommendation should have its own area, which can be numbered or bulleted.
Begin progress notes with a clear and informative header containing client identification details, session date, and therapist name. Be objective and specific when describing client progress, focusing on measurable goals. Use standardized assessment scales and tools to quantify and track improvements accurately.
Your occupational therapy SOAP notes template should have 4 sections: Subjective, Objective, Assessment, and Plan. Keep SOAP notes simple and get straight to the point. This makes documentation scannable and easy for you and other healthcare providers to understand.

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