Occupational Therapist Progress Note - Home Visit

**Purpose of Home Visit:** [Describe the specific occupational therapy purpose of the home visit, focusing on functional goals, specific areas of occupational performance being assessed or addressed (e.g., ADLs, IADLs, leisure, work), and any particular environmental factors being evaluated.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".) **Present at Home Visit:** [List all individuals present during the home visit, including the client, family members, caregivers, and any other relevant persons (e.g., support workers, other therapists, include Author - Occupational Therapist), "name" - "position/relationship to patient"] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".) **Subjective:** [Document the patient's and/or caregiver's self-reported information relevant to occupational performance, including their perspectives on current issues, concerns, priorities, goals related to daily activities, perceived barriers, and any relevant history or background information impacting occupational engagement. Outline in a bullet list.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".) **Objective:** [Record objective observations made during the home visit relevant to occupational performance and the environment. This includes: Patient's physical and cognitive status as observed during activities or interactions (e.g., mobility, coordination, attention, problem-solving). Performance observed during specific tasks or activities (e.g., method, efficiency, safety, level of assistance required for ADLs/IADLs). Environmental factors impacting occupational performance (e.g., home layout, accessibility, equipment present, safety hazards). Results of any standardized or non-standardized assessments administered (specify assessment and key findings/scores). Observations of interaction patterns and communication relevant to functional tasks. Outline in a bullet list.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".) **Assessment/Analysis:** [Provide a professional occupational therapy analysis of the subjective and objective information. Interpret the findings in relation to the patient's occupational performance challenges, strengths, participation levels, and the impact of the environment or condition. Justify the need for OT intervention or continued services. Including any clinical justification that is provided. Outline in a bullet list.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".) **Intervention/Treatment:** [Describe the specific occupational therapy interventions provided during the session. Including any clinical justification that is provided. This should detail: Specific activities or tasks performed (e.g., ADL training, environmental modification, equipment trial, therapeutic exercise related to function, cognitive strategy training). Therapist's techniques and approach used. Education or training provided to the patient or caregivers. Adaptive equipment or strategies introduced or practiced. Outline in a bullet list.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".) **Response to Intervention/Progress:** [Document the patient's response to the interventions provided during the session. Describe their participation, performance level, level of assistance required, and any immediate changes or progress observed in occupational performance or related factors (e.g., safety, independence, confidence). Note any difficulties encountered. Outline in a bullet list.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".) **Plan:** [Outline the plan for future occupational therapy interventions, including: Specific goals being targeted or next steps in the treatment plan. Planned future interventions or activities. Recommendations made (e.g., equipment prescription, home modifications, referral to other services). Schedule for future visits or follow-up actions required. Discussion regarding patient/caregiver homework or practice. Outline in a bullet list.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List in bullet points with "-".) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder blank or omit the placeholder and its heading completely.) (Use as many lines, paragraphs or bullet points with "-", depending on the format, as needed to capture all the relevant information from the transcript.)