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Occupational Therapist Template

SAW Initial template

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

Need a comprehensive occupational therapy assessment? This SAW Initial template is designed for occupational therapists to document a patient's injury, functional abilities, and plan for returning to work. It covers injury details, current physical tolerances, and pre-injury job tasks. This template helps therapists create detailed notes, including suitable work modifications and employer support. With Heidi, this template can be quickly populated from your visit transcript, saving you time and ensuring thorough documentation for your patients. This template is perfect for occupational therapists looking for a structured approach to patient assessment and return-to-work planning.

Preview template

Summary of injury and treatment Patient sustained a right shoulder rotator cuff tear on 15 October 2024 during a fall at work. Underwent arthroscopic repair on 20 October 2024. Currently in a sling and participating in physiotherapy. Current functional tolerances Patient is currently unable to lift more than 5 pounds with the right arm. Limited range of motion in the right shoulder. Able to perform light activities of daily living with modifications. Upcoming medical appointments Follow-up appointment with Dr. Smith on 15 November 2024. Physiotherapy sessions twice a week. Current medical certificate Patient is currently signed off work until 1 December 2024. Restrictions include no lifting, pushing, or pulling with the right arm. Pre-injury role title Warehouse worker. Normal working hours/days Monday to Friday, 8:00 AM to 4:00 PM. Work tasks Loading and unloading trucks, moving packages, operating a forklift. Physical requirements of tasks Frequent lifting of up to 50 pounds, repetitive arm movements, prolonged standing. Suitable work tasks for gradual return to work Light administrative duties, such as data entry and phone calls. Modified tasks involving minimal use of the right arm. Employer concerns and support of programme, barriers or opportunities Employer is supportive of a gradual return to work. They are willing to provide modified duties and workplace accommodations. No barriers identified at this time. Medications: * Ibuprofen 400mg, as needed for pain * Paracetamol 500mg, as needed for pain Allergies: * No known drug allergies. Review of systems: * Musculoskeletal: Right shoulder pain, stiffness, and limited range of motion. Physical examination findings: * Vitals: BP 120/80, HR 72, RR 16, Temp 37°C * Right shoulder: Swelling and bruising present. Limited active and passive range of motion. Pain on palpation. Assessment and differential diagnosis: * Right shoulder rotator cuff tear, post-operative. Plan of care: * Continue physiotherapy twice a week. * Home exercise program as prescribed by physiotherapist. * Follow-up with Dr. Smith on 15 November 2024. * Occupational therapy to assess functional capacity and facilitate a safe return to work. * Review of work duties and potential modifications. * Date: 1 November 2024
Summary of injury and treatment [summary of injury and treatment] (Provide a concise summary of the patient's injury or injuries, including date of incident, nature of injury, body part(s) affected, and treatment to date. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Current functional tolerances [current functional tolerances] (Describe the patient’s current ability to stand, sit, walk, lift, carry, bend, and perform other relevant physical tasks. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Upcoming medical appointments [upcoming medical appointments] (List any upcoming appointments including provider, date, and purpose. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Current medical certificate [current medical certificate status] (Provide the status or summary of any current medical certificate, including capacity, restrictions and expiry date. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Pre-injury role title [pre-injury job title] (Insert the patient’s role title prior to the injury. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Normal working hours/days [pre-injury work schedule] (List usual working hours and days prior to injury. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Work tasks [pre-injury work tasks] (Summarise primary duties and responsibilities of the patient’s pre-injury role. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Physical requirements of tasks [physical demands of job tasks] (Describe the physical components of the role such as lifting, standing, sitting, repetitive movements, etc. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Suitable work tasks for gradual return to work [suitable duties for return-to-work programme] (Suggest modified or reduced duties that align with current functional tolerances and support a gradual return to work. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Employer concerns and support of programme, barriers or opportunities [employer input on return-to-work] (Summarise any employer concerns, willingness to support return-to-work programmes, barriers identified, and opportunities for workplace accommodations. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [document current medications, including dosages and any over-the-counter supplements or herbal remedies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [document any known allergies, including drug, food, and environmental allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [document review of systems, including any symptoms or issues related to different body systems (e.g., cardiovascular, respiratory, gastrointestinal, musculoskeletal, neurological, etc.)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [document physical examination findings, including vital signs and any notable observations from the physical exam] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [document assessment and differential diagnosis, including the clinician's evaluation of the patient's condition and possible diagnoses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [document plan of care, including any recommended tests, treatments, referrals, and follow-up appointments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (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 that 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.)
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Specialty

Occupational Therapist

Used

22 times

Type

Note

Last edited

8/13/2025

Created by

Anwen Holtshousen

Document

BIST

Anonymous

Occupational Therapist, New Zealand

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