Occupational therapy mental health documentation

OT practitioners spend lots of time on documentation.

Our notes help us track patient progress, communicate with other healthcare providers, and defend our rationale for our treatment choices.

But, as we all know, charting can take FOREVER—and we might not have as much time as we’d like to do it justice.

We are constantly grappling between wanting to write the perfect OT note—one that succinctly says what we did and why we did it—and finishing our documentation as quickly as possible.

My vision (and I’ll admit, it’s a grand one) is to help you create treatment notes that clearly communicate the skilled OT care you provided—without making you lose your mind in the process.

In this guide, you’ll find:

DO’s and DON’Ts of Writing Occupational Therapy Documentation

We know documentation varies widely from setting to setting, so we are using the universal SOAP (Subjective, Objective, Assessment, Plan) note structure to break down our advice.

Even if you don’t use this exact structure in your notes, your documentation probably has all of these dimensions.

Subjective (S)

DO use the subjective part of the note to open your story

Each note should tell a story about your patient, with the subjective portion setting the stage.

Try to open your note with feedback from the patient on what is and isn’t working about their therapy sessions and home exercise program. For example, you can say any of the following to get your note started:

“Patient states she was excited about ____.”
“Patient reports he is frustrated he still can’t do ____.”
“Patient had a setback this past weekend because ____.”

In sentence one, you’ve already begun to justify why you’re there! If you need some good questions to draw out this kind of feedback from patients, check out Good Questions for OTs to Ask.

DON’T go overboard with unnecessary details

Let’s admit it: we are storytellers, and we like to add details. But, we’ve all seen notes with way too much unnecessary information. Here are a few things you can generally leave out of your notes:

“Patient was seated in chair on arrival.”
“Patient let me into her home.”
“Patient requested that nursing clean his room.”

Details are great, because they help preserve the humanity of our patients. But, it’s really not necessary to waste your precious time typing out statements like these.

Channel your inner English major. If a detail does not contribute to the story you are telling—or, in OT terms, contribute to improving a patient’s function—you probably don’t need to include it 🙂

Objective (O)

DO go into detail about your observations and interventions

The objective section of your evaluation and/or SOAP note is often the longest.

This section should contain objective measurements, observations, and test results. Here are a few examples of what you should include:

Manual muscle tests (MMTs)
Range of motion measurements (AAROM, AROM, PROM, etc.)
Level of independence (CGA, MIN A, etc.)
Functional reporting measures (DASH screen, etc.)
Objective measures from assessments related to the diagnosis

For a comprehensive list of objective measurements that you can include in this section, check out our blog post on OT assessments. We compiled over 100 assessments you can use to gather the most helpful data possible.

Assessment (A)

DO show clinical reasoning and expertise

The assessment section of your OT note is what justifies your involvement in this patient’s care.

Here, you’ll synthesize how the patient’s story aligns with the objective measurements you took (and overall observations you made) during this particular treatment session.

Your assessment should answer these questions:

How does all of this information fit together?
Where (in your professional opinion) should the patient go from here?
Where does OT fit into the picture for the patient’s treatment plan?

DON’T skimp on the assessment section

The assessment section is your place to shine! All of your education and experience should drive this one crucial paragraph.

And yet…

We tend to simply write: “Patient tolerated therapy well.” Or we copy and paste a generic sentence like: “Patient continues to require verbal cues and will benefit from continued therapy.”

Lack of pizazz aside, that’s not enough to represent the scope of your education and expertise—nor the degree of high-level thinking required to carry out your treatments.

Instead, consider something like: “Patient’s reported improvements in tolerance to toileting activities demonstrate effectiveness of energy conservation techniques she has learned during OT sessions. Improved range of motion and stability of her right arm confirms that her use of shoulder home exercise plan is improving her ability to use her right upper extremity to gain independence with self care.”

Plan (P)

DON’T get lazy

I once took a CEU course on note-writing that was geared toward PTs.

It felt like most of the hour was spent talking about how important it is to make goals functional. But we OTs already know this; function is our bread and butter.

So, why do many OTs insist on writing things like: “Continue plan of care as tolerated”?

Not only do utilization reviewers hate that type of generic language, but it also robs us of the ability to demonstrate our clinical reasoning and treatment rationale!

DO show proper strategic planning of each patient’s care

This section isn’t rocket science. You don’t have to write a novel. But, you do need to show that you’re thinking ahead and considering how care plans will change as patients progress through treatment.

Consider something like this: “Continue working with patient on toileting while gradually decreasing verbal and tactile cues, which will enable patient to become more confident and independent. Add stability exercises to home exercise program to stabilize patient’s right upper extremity in the new range. Decrease OT frequency from 3x/week to 2x/week as tolerated.”

Short, sweet, and meaningful.

General DO’s and DON’TS for documentation

In every good story, there’s a hero and a guide. In the case of OT notes, your patient is the hero—and you are the guide. To take that metaphor one step further: If the patient is Luke Skywalker, you are Yoda.

I think as therapists, we tend to document only one part of the story.

Some of us focus on the hero’s role: “Patient did such and such.”

Others focus on what we, the guide, accomplish with our skilled interventions: “Therapist downgraded, corrected, provided verbal cues.”

But, a really good note—dare I say, a perfect note—shows how the two interact.

If your patient tells you in the subjective section that they are not progressing as quickly as they would like, what did you, as the therapist, do to upgrade their intervention? Your notes should make it apparent that you and the patient are working together as a team.

Let’s look at a few examples:

“Patient reported illness over the weekend; thus, activities and exercises were downgraded today. Plan to increase intensity when patient feels fully recovered.”
“Patient has made good progress toward goals and is eager for more home exercises. Plan to add additional stability work at next visit.”

DO be very careful with abbreviations

While I was creating this blog post, I read every piece of advice I could find on documentation—and I had to chuckle, because there was simply no consensus on abbreviations.

Abbreviations are obviously great for saving time—but they can make our notes cryptic (read: useless) to those outside of our specialty.

In an ideal world, we type the abbreviation and our smartie computer fills in the full word or phrase for us. And, for those of us who use an EMR on Google Chrome, this is exactly what can happen. WebPT, for example, allows this integration.

If you don’t already use keyboard shortcuts, contact your IT department and see if there are any options within your EMR. If you aren’t able to implement these shortcuts, I highly recommend that you request them!

I’ve got an article about OT documentation hacks that delves more into the topics of text expanders and abbreviations!

Okay, after all of that, I bet you’re ready to see an OT evaluation in action. You’re in luck, because I have an example for you below!

OT Documentation Cheat Sheets

One of the first things I did in any new setting was make myself a documentation template/cheat sheet.

During my orientation, I would ask a fellow OT if I could see an example of the notes they were writing. Then I would use their example as I crafted my first notes. When I made a note I was happy with, I would print a copy and keep it on my clipboard.

I think the key here is to make the cheat sheet that is right for you. You may simply want a list of power words to use in your notes. Or, you may want a full-fledged note. It may be electronic or something you print and keep at your desk.

In one setting, I created an eval checklist, made copies of it, and used it to take notes so I always had all of the info handy.

At the end of the day, each setting—and therapist—is different. So, take the time to make the cheat sheet that will be most useful to you.

Here are some examples to get you started:

Example Outpatient Occupational Therapy Evaluation

Okay, we’re getting to the good stuff—full OT note examples.

Below is an example outpatient hand therapy note. I chose to feature this type of note because they tend to be on the longer side, thus allowing me to showcase multiple aspects of note writing.

Name: Phillip Peppercorn

MRN: 555556

DOB: 05/07/1976

Evaluation date: 12/10/18

Diagnoses: G56.01, M19.041

Treatment diagnoses: M62.81, R27, M79.641

Referring physician: Dr. Balsamic

Payer: Anthem

Visits used this year: 0

Frequency: 1x/week

Subjective

Patient is a right-handed male software engineer who states he had a severe increase in pain and tingling in his right hand, which led to right carpal tunnel release surgery on 11/30/18. He presents to OT with complaints of pain and residual stiffness while performing typing movements, stating, “I’m supposed to go back to work in three weeks, and I don’t know how I will be able to function with this pain.”

Post surgery, patient complains of 2/10 pain at rest and 7/10 shooting pain at palmar region extending to second and third digits of right hand when working at his computer for extended periods of time and when doing basic household chores that involve carrying heavy objects (like laundry and groceries). The numbness and tingling he was feeling prior to surgery has resolved dramatically.

Past medical/surgical history: anemia, diabetes, right open carpal tunnel release surgery on 11/30/18

Hand dominance: right dominant

IADLs: independent, reports difficulty typing on phone and laptop, and with opening and closing his laptop computer since surgery

ADLs: opening drawers at work, opening door handles at office building

Living environment: lives alone in single-level apartment

Prior level of functioning: independent in work duties, activities of daily living, and instrumental activities of daily living.

Occupational function: works a job as a software engineer; begins light-duty work with no typing on 12/20, MD cleared for 4 initial weeks

Objective

Range of motion and strength:

Left upper extremity: Range of motion within functional limits at all joints and on all planes.

Right upper extremity: Right shoulder, elbow, forearm, digit range of motion all within normal limits on all planes.

Right wrist:

Flexion/extension—Strength: 4/5, AROM: 50/50, PROM: 60/60

Radial/ulnar deviation—Strength: 4/5, AROM: WNL, PROM: NT

Standardized assessments:

Dynamometer

Left hand: 65/60/70

Right hand: 45/40/40

Boston Carpal Tunnel Outcomes Questionnaire (BCTOQ)

Symptom Score = 2.7

Functional Score = 2.4

Sutures were removed and wound is healing well with some edema, surgical glue, and scabbing remaining.

Patient was provided education regarding ergonomic setup at work and home, along with home exercise program, including active digital flexor tendon gliding, wrist flexion and extension active range of motion, active thumb opposition, active isolated flexor pollicis longus glide, and passive wrist extension for completion 4-6x/day each day at 5-10 repetitions.

He was able to verbally repeat the home exercise program and demonstrate for therapist, and was given handout.

Patient was given verbal and written instruction in scar management techniques and scar mobilization massage (3x/day for 3-5 minutes). He was also issued a scar pad to be worn overnight, along with a tubular compression sleeve.

Assessment

Mr. Peppercorn is a 46-year-old male who presents with decreased right grip strength and range of motion, as well as persistent pain, following carpal tunnel release surgery. These deficits have a negative impact on his ability to write, type, and open his laptop and door handles. Anticipate patient may progress more slowly due to diabetes in initial weeks, but BCTOQ reflects that the patient is not progressing as quickly as normal, and is at risk of falling into projected 10-30% of patients who do not have positive outcomes following carpal tunnel release. Patient will benefit from skilled OT to address these deficits, adhere to post-op treatment protocol, and return to work on light duty for initial four weeks.

Plan of care

Recommend skilled OT services 1x/week consisting of therapeutic exercises, therapeutic activities, ultrasound, phonophoresis, e-stim, hot/cold therapy, and manual techniques. Services will address deficits in the areas of grip strength and range of motion, as well as right hand pain. Plan of care will address patient’s difficulty with writing, typing, and opening and closing his laptop and door handles.

Short Term Goals (2 weeks)

Patient will increase dynamometer score in bilateral hands to 75 lb in order to do laundry.
Patient will increase right digit strength to 3+/5 in order to open door handles without using left hand for support.

Long Term Goals (6 weeks)

Patient will increase right wrist strength to 5/5 to carry groceries into his apartment.
Patent will increase active range of motion in wrist to within normal limits in order to open and close his laptop and use door handles without increased pain.
Patient will increase dynamometer score in bilateral hands to 90 lb in order to return to recreational activities.
Patient’s Boston Carpal Tunnel Outcomes Questionnaire score will decrease to less than 1.7 on symptoms and function to return to work and social activities without restrictions.

Signed,

O. Therapist, OTR/L

97165 – occupational therapy evaluation – 1 unit

97530 – therapeutic activities – 1 unit (15 min)

97110 – therapeutic exercises – 2 unit (30 min)

OT Documentation Examples in the OT Potential Club

In the OT Potential Club, our OT evidence-based practice club, you can also access our library of documentation examples.

These are real-life documentation examples. Every setting and facility is different, so they are not intended to be copied for your own use. Rather, they are designed to be discussion-starters that help us improve our documentation skills.

Here’s the examples we have so far:

Acute Care—Adults & Pediatric

Acute Care OT Eval (s/p THA)
Acute Care OT Tx Note (s/p THA)
Acute Pediatric OT Eval (diagnosis: acute myeloid leukemia)
Acute Pediatric Tx Note (diagnosis: acute myeloid leukemia)
Inpatient Rehabilitation Eval (diagnosis: ischemic stroke)

Assisted Living Facilities (ALF)

ALF OT Eval (s/p fall)
ALF Treatment Note (s/p fall)

Early Intervention (EI)

EI Eval (diagnosis: Down’s Syndrome)
EI Tx Note (diagnosis: Down’s Syndrome)
Telehealth EI Development Eval

Home Health

Home Health OT Eval (s/p femur fx)

Outpatient (OP)—Adults & Pediatric

Home-visit Treatment Note (Showcasing caregiver support)
OP Eval (diagnosis: POTS)
OP OT Eval (diagnosis: carpal tunnel release)
OP OT Eval (s/p concussion)
OP Pediatric Eval (diagnosis: autism, ADHD)
OP Pediatric OT Eval (diagnosis: autism)
OP Tx Note (diagnosis: Multiple Sclerosis, participatory medicine tx approach)
OT Treatment Note (s/p concussion)
OP Tx Note (diagnosis: post-stroke, self-management tx approach)
Power Wheelchair Evaluation
Power Wheelchair Treatment Note
Pediatric Telehealth Eval—Private Pay
Pediatric Telehealth Tx Note—Private Pay

Mental Health

OT Inpatient Psych Eval (adolescent with suicidal ideation)
OT Inpatient Psych Treatment Notes (adolescent with suicidal ideation)

School-based OT

School-based OT Eval Report: (diagnosis: autism)
School OT Eval (diagnosis: Down’s Syndrome)
Telehealth School OT Eval Example (diagnosis: trisomy 21)
Telehealth School OT Tx Note (diagnosis: trisomy 21)

Skilled Nursing Facility (SNF)

SNF OT Eval (s/p THA)
SNF OT Tx Note (s/p THA)

Conclusion

Documentation can get a bad rap, but I believe OT practitioners are uniquely poised to write notes that are meaningful to other healthcare practitioners and patients alike.

It seems inevitable that our patients will gain easier access to their notes over the next decade, and when they do, I want our documentation to stand out as relevant and useful.

Special Thanks

Thank you to The Note Ninjas, Brittany Ferri (an OT clinical reviewer), and Hoangyen Tran (a CHT) for helping me create this resource!

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