Originally published – March 2021. Republished for relevance May 2024.

We’ve covered intake, invoicing, and consent form templates, but a crucial part of being an occupational therapist is taking progress notes for patients. This time we’ll be reviewing progress note templates for Occupational Therapy.

While Occupational Therapists record each step of the client’s progress (from intake to the conclusion of a client’s treatment plan), progress notes are the detailed snippets of information along that journey. They show the importance of the service an occupational therapist offers for their clients and guides them along their treatment journey and supports them in between sessions. A progress note is also an insight into how a practitioner works and the value that they bring to the client relationship.

The basics of an Occupational Therapy progress note template:

Must include client-specific details (on each page), a review of what goals/actions were taken during the session by the client and the practitioner, and the practitioners’ assessment of the client’s actions, followed by corresponding updates, and recommendations to be implemented prior to the next session.

Outside these four basic areas, there’s room for each Occupational Therapist to customize their own personalized version that suits the way they treat and communicate with clients.

Here’s some more information about what to include in your occupational therapy progress note template:

1. Client’s basic information – Details such as first and last name, phone, age, address, PHN, etc. are required on each page of documentation. While you may have this information recorded in other places, professional documentation guidelines require each page of documentation or client work within the client chart to have your client’s information listed, usually name, DOB, and PHN is enough.
2. Consent – To meet professional guidelines you must obtain informed consent at the beginning of each treatment session and document that. This can be as simple as a statement to your client such as “Today we are going to work on ….., are you okay with that?” “Do you have any questions?” Then in your documentation, a simple statement such as “consent for today’s treatment session obtained verbally.” 
3. Session information – Record the session date, length of time, location, and who was present during the session.
4. Observation and subjective statements – Did your client comment on the activities presented?  Or on things that happened during the time between sessions? What does your client report? And what are you able to observe?
5. Actions and assessment – What did you observe your client doing in response to the activities and treatments offered? And what actions did you take based on their response? What was your assessment of your client’s actions? 
6. Recommendations or Follow-up required – What recommendations do you have for your client to follow up on between sessions. Is there any other follow-up required for you or your client?

As an occupational therapist, your goal is to help others, not spend time completing non-billable tasks.

Access the occupational therapy progress note template:

Are you interested in an Occupational Therapy progress note template? This template was invaluable to me in my early career. Using an automated, centralized documentation system with integrated goal tracking has reduced my charting time and improved my documentation quality. Check out this video and see how the Therabyte Smart Trees feature is changing the way practitioners document progress. 

If you couldn’t already tell, I’m a huge advocate for automation and helping occupational therapists transition to digital documentation.

When you’re ready to jump to the next level, Therabyte can automate the progress note process for you!

START MY FREE TRIAL

Looking forward to connecting soon, please reach out with any comments or questions at team@therabyte.com.

Ashley Reina,

Occupational Therapist & Co-founder of Therabyte App