Skilled OT Documentation

Skilled OT Documentation Template

Subjective:

“Pt reports [pain/fatigue/frustration/limited ability to ___] since last session. Pt attempted [task] independently with [result/symptom/success].”

Examples:

• “Pt reports increased confidence with toilet transfers but continues to require rest breaks during dressing.”

• “Pt states RUE pain is improving but avoids using it during grooming tasks.”

Objective:

Objective means “not influenced by personal feelings or opinions in considering and representing facts.”

These are assistance levels for ADLs, MMT/strength levels, ROM, vitals, balance, transfer assistance levels. 

Skilled Care Provided:

1. Functional Task or ADL Practiced:

“Patient participated in [task] (e.g., grooming, dressing, cooking prep) using [adaptive strategy/technique].”

2. Clinical Reasoning & Adjustment:

“OT provided [verbal/tactile/visual cues, task modification, sequencing support] due to [limitation or observed issue].”

3. Strategy or Focus (view “Examples of Strong, Skilled OT Documentation Phrases”) :
🟡 Energy Conservation / Task Simplification
🔵 Compensatory / Adaptive Strategies and Equipment
🟠 Alternate Body Mechanics & Joint Protection
🟢 Graded Reintroduction of Movement / Use
🔴 Scapular Stabilization / Movement Patterns
🟣 Cognition, Sequencing, Executive Function

“Patient trained in [strategy] to address [specific deficit] during [ADL].”

Examples:

• “Pt practiced one-handed grooming techniques due to RUE fracture; educated in mirror feedback to reduce compensatory trunk lean.”

• “Task modified for energy conservation via seated positioning and rest breaks.”

• “Pt trained in scapular setting during reaching task; OT provided verbal and tactile cueing to improve rhythm.”

[Assessment]  Patient Response to Treatment / Progress:

“Patient [demonstrated/improved/required assistance] with [task].”

Include measurable changes where possible:

• “Improved from MOD A to CGA with lower body dressing.”

• “Able to perform task with fewer cues, less fatigue, or increased safety awareness.”

Examples:

• “Patient progressed from MOD A to CGA for lower body dressing using adaptive equipment and sequencing cues.”

• “Patient now able to prepare cold meal with 2-step verbal prompts and seated positioning to reduce fall risk.”

• “Patient able to transfer with walker and use RUE for stabilization during toilet hygiene with supervision.”

[Assessment] Justification for Further Treatment:

“Continued OT warranted due to [risk, goal, or specific skill being addressed].”

Examples:

• “Pt continues to require skilled training for safe reintroduction of RUE use post-fracture and prevention of joint contracture.”

• “OT needed to provide ongoing cognitive retraining and environmental modifications for safe task performance.”

Plan for Next Visit:

“Next session will focus on [task progression/adaptive trial/retraining/education].”

Examples of Strong, Skilled OT Documentation Phrases

 🟡 “Energy Conservation / Task Simplification”

These are often overused vaguely. Try to ensure details are specific like:

• “Instructed patient in sequencing hygiene tasks to reduce positional changes and minimize fatigue.”

• “Trained patient in combining grooming tasks (e.g., brushing hair while seated) to conserve energy.”

• “Patient educated in use of seated dressing and modified workspace to reduce exertion.”

• “Implemented 5-min activity, 5-min rest schedule and monitored tolerance.”
  
  

 🔵  “Compensatory / Adaptive Strategies and Equipment”

Make sure it’s not just the buzzword. What was done?

• “Patient trained in use of sock aid and reacher for LE dressing due to spinal pain limiting flexion.”

• “Demonstrated one-handed dressing technique due to RUE weakness; patient able to replicate shirt donning with min assist.”

• “Patient practiced modified bathing routine using handheld showerhead and tub bench; safety strategies reviewed.”

• “Patient instructed in use of built-up utensils to reduce wrist strain and promote independent feeding.”

🟠 “Alternate Body Mechanics & Joint Protection”

Great for ortho and pain conditions.

• “Educated patient to avoid shoulder abduction beyond 90° during grooming to prevent impingement.”

• “Trained patient to use step-in approach vs. pivot to reduce lumbar strain during toilet transfers.”

• “Patient cued to engage glutes and maintain neutral spine during sit-stand transitions.”

• “Reviewed protective positioning strategies to avoid weight-bearing on healing UE fracture.”

🟢 “Graded Reintroduction of Movement / Use”

For post-op, fracture, or pain-limited patients.

• “Began light functional use of RUE with grooming tasks under supervision; monitored for pain and compensatory patterns.”

• “Introduced light object manipulation (e.g., towel wringing) as initial re-engagement of grip and shoulder coordination.”

• “Patient completed 3 sets of shoulder pendulums and table-top wipe tasks to reintroduce scapular mobility.”

• “Progressed from one-handed ADL tasks to two-handed with therapist cueing and activity modification.”

 🔴 “Scapular Stabilization / Movement Patterns”

Especially important for shoulder rehab.

• “Observed reduced scapulohumeral rhythm during reaching task; provided verbal and tactile cues for scapular retraction.”

• “Performed scapular mobility drills (wall slides, assisted elevation) to address guarding patterns post-fracture.”

• “Educated patient on scapular setting prior to UE exertion to prevent overuse of cervical and upper trap musculature.”

• “Patient practiced reaching tasks with focus on controlled scapular upward rotation.”

🟣 “Cognition, Sequencing, Executive Function”

Should be seen in neuro, ortho (post-op confusion), and chronic illness.

• “Patient required verbal prompts to initiate hygiene task; deficits in initiation and sequencing noted.”

• “Patient demonstrated difficulty organizing steps to dress; task was broken down into single-step commands with visual modeling.”

• “Cognitive retraining focused on safe stove use via simulated cooking task; patient able to recall 3-step safety process.”