Occupational Therapist Template

OT Progress Note

A professional Occupational Therapist template for healthcare professionals.

About this template

Need a clear and concise way to document your occupational therapy sessions? Our OT Progress Note template is designed for occupational therapists to efficiently record client progress, session activities, and treatment plans. This template helps you capture essential details like client participation, discussions, and homework assignments. With Heidi, this template can be quickly populated from your session transcript, saving you time and ensuring accurate documentation. Streamline your note-taking process and focus on what matters most: your clients' well-being.

Preview template

OT Progress Note Occupational Therapist 1 November 2024 Session Attendance and Focus: The client, [insert age] year old, attended the occupational therapy session as scheduled. The primary focus of the session was to address the client's difficulties with fine motor skills and activities of daily living (ADLs), specifically dressing and meal preparation. The session involved a combination of therapeutic activities, including hand exercises, simulated dressing tasks, and discussion of adaptive equipment. Client Presentation and Observations: The client presented with a positive and cooperative attitude throughout the session. They appeared engaged and motivated to improve their skills. The client reported experiencing some frustration with dressing tasks, particularly buttoning shirts and zipping trousers. The client demonstrated good verbal communication skills and was able to articulate their challenges and goals effectively. Rapport and Client Reports: The client actively participated in rapport-building activities, sharing updates about their week and expressing their desire to regain independence in ADLs. The client reported feeling more confident in their ability to manage their daily routines with the support of the therapy sessions. Involvement of Additional Individuals: No additional individuals were involved in this session. Topic of Discussion 1 - Fine Motor Skills Exercises - Key discussion points included the importance of regular hand exercises to improve strength and dexterity. The therapist demonstrated various exercises, such as finger stretches, pinching exercises, and using putty. The client was encouraged to practice these exercises daily. - The client demonstrated understanding by actively participating in the exercises and asking clarifying questions about the proper techniques. Topic of Discussion 2 - Adaptive Equipment for Dressing - Key discussion points included the use of adaptive equipment to assist with dressing tasks. The therapist introduced the client to button hooks, zipper pulls, and dressing sticks. The benefits and limitations of each tool were discussed. - The client expressed interest in trying out the adaptive equipment and asked for guidance on how to obtain them. Homework: The client was assigned to practice the hand exercises twice a day and to explore the use of adaptive equipment at home. The client was provided with a handout detailing the exercises and a list of local suppliers for adaptive equipment. Plan: - Continue with hand exercises and fine motor skill activities. - Trial the use of adaptive equipment for dressing. - Schedule a follow-up session to review progress and adjust the treatment plan as needed.

[describe the client's attendance, the primary focus of the session, and any specific activities undertaken] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [describe the client's presentation, mood, and any notable interactions or observations during the session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [describe the client's participation in rapport-building activities and any reports made by the client regarding their current circumstances or progress] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [describe the involvement of any additional individuals in the session, including their presence, duration, and any agreed-upon goals or discussions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [topic of discussion 1] - [key discussion points, education or reflections by the therapist and/or client] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.) - [client's understanding and any examples provided in relation to this topic] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [topic of discussion 2] - [key discussion points, education or reflections by the therapist and/or client] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.) - [client's understanding and any examples provided in relation to this topic] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) [describe any homework or tasks assigned to the client, including any materials provided and the involvement of other individuals in supporting the homework] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Plan: - [action step 1 for the client based on the session topics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bullet point.) - [action step 2 for the client based on the session topics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bullet point.) - [action step 3 for the client based on the session topics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bullet point.) (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 or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

Browse more templates

Use this template