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Occupational Therapist Template

Curamus Occupational Therapy (DCAPS level 2)

A professional Occupational Therapist template for healthcare professionals.
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About this template

Enhance your clinical record-keeping with our 'Curamus Occupational Therapy (DCAPS level 2)' template, specifically designed for occupational therapists. This detailed occupational therapy note template streamlines the documentation of assessment findings, therapeutic interventions, and progress for paediatric clients, aligning with DCAPS level 2 criteria. Easily capture observations on general participation, postural ocular skills, bilateral integration, visual perception, and visual motor abilities. Perfect for creating comprehensive and structured notes that clearly outline client status and treatment plans. With Heidi, our AI medical scribe, this template intelligently populates key sections directly from your session's transcript, ensuring accuracy and saving you valuable time on administration.

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Date: 1 November 2024 Activity: Initial assessment session for a 7-year-old male presenting with difficulties in motor coordination and sensory processing, referred by his paediatrician. The session focused on observing functional tasks and play-based activities. - Engaged in structured play involving puzzles and building blocks to assess fine motor skills. - Participated in gross motor activities including obstacle course navigation and ball games. - Utilised sensory integration equipment (swing, crash mat) to observe sensory responses. General Participation and Behaviour: - Maintained eye contact during interactions and responded appropriately to questions. - Followed multi-step instructions consistently after initial clarification. - Demonstrated good turn-taking during play activities with the therapist. - Exhibited moderate concentration levels, occasionally requiring redirection. - Showed some sensory seeking behaviours, particularly for vestibular input, but was easily regulated. Overall score rating: Green Postural Ocular: - Displayed fair postural control with some noticeable sway during single-leg stance. - Core strength appeared adequate for most tasks, but trunk rotation was somewhat limited. - Vestibular processing observations indicated a need for further assessment, as he actively sought out rotary movements. - Balance was age-appropriate for static tasks but showed minor instability during dynamic movements. - Eye movements were generally smooth, but some difficulty with visual tracking across midline was noted. Overall score rating: Amber Bilateral Integration and Sequencing: - Successfully imitated simple bilateral movements, but more complex alternating movements were challenging. - Ball skills (catching, throwing) were below age expectations, often using a global rather than refined approach. - Body awareness appeared developing, with occasional difficulty identifying left/right body parts quickly. - Scissor skills were emerging, but precision and endurance for cutting shapes were limited. Overall score rating: Amber Visual Perception and Visual Motor: - Demonstrated good spatial relations in puzzle completion but struggled with more abstract visual-spatial tasks. - Visual closure skills were adequate for common objects. - Visual motor integration, as assessed through drawing tasks, indicated some difficulty with letter formation and geometric shapes. Overall score rating: Amber Plan: - Develop a personalised therapeutic programme focusing on improving bilateral coordination, visual motor integration, and refining sensory regulation strategies. - Recommend a frequency of one 45-minute session per week for 10 weeks. - Suggest a home programme including activities such as daily 'animal walks', simple catching games, and cutting practice with age-appropriate materials.
Date: [Date of assessment or session] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Activity: [Description of session context including co-treatment details or reason for referral] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Therapeutic activities and interventions performed during the session] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) General Participation and Behaviour: - [Observations regarding social interaction, ability to follow instructions, waiting, turn taking, concentration, and sensory regulation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Overall score or rating for this section such as a colour code or summary] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Format as: Overall score rating: [score].) Postural Ocular: - [Assessment findings related to postural control, core strength, vestibular processing, balance, and eye movements] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Overall score or rating for this section such as a colour code or summary] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Format as: Overall score rating: [score].) Bilateral Integration and Sequencing: - [Observations of imitation of bilateral movements, ball skills, body awareness, and scissor skills] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Overall score or rating for this section such as a colour code or summary] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Format as: Overall score rating: [score].) Visual Perception and Visual Motor: - [Assessment of spatial relations, visual closure, and visual motor integration] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) [Overall score or rating for this section such as a colour code or summary] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Format as: Overall score rating: [score].) Plan: - [Description of the plan including therapeutic goals, frequency of sessions, and any home programme recommendations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.)
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Specialty

Occupational Therapist

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Type

Note

Last edited

24/03/2026

Created by

Rebekka Maseko

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Anonymous

Occupational Therapist, New Zealand

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