📝 OT FIELDWORK DOCUMENTATION CHEAT SHEET

🔑 1. Your Mental Formula (ALWAYS think this way)

👉 What did I see → What does it mean → Why does it matter → What did I do

🧠 2. Power Sentence Structure (use this for EVERYTHING)

👉
Client demonstrated [deficit/skill] during [activity], requiring [level of assistance], impacting [function].

Example:

• Client demonstrated decreased visual-spatial skills during puzzle task, requiring mod verbal and visual cues, impacting task accuracy and independence.

🎯 3. Cueing Levels (say this quickly & consistently)

• Independent

• Min cues (1–2)

• Mod cues (3–5)

• Max cues (constant)

👉 You can specify:

• verbal

• visual

• tactile/physical

Example:

• “required mod verbal cues and occasional physical prompting”

⏱️ 4. Attention & Behavior Phrases

Instead of explaining a lot, use:

• Sustained attention for ~__ minutes

• Decreased attention with increased task complexity

• Impulsivity impacting task initiation

• Decreased inhibitory control (rushing)

• Improved engagement with self-directed tasks

• Benefits from structured tasks / clear expectations

🧩 5. Executive Functioning Quick Terms

• Planning

• Initiation

• Inhibitory control

• Self-monitoring

• Cognitive flexibility

👉 Example:

• “demonstrated decreased inhibitory control and self-monitoring”

👁️ 6. Visual-Perceptual Quick Terms

• Visual discrimination

• Visual closure

• Visual-spatial relations

• Visual scanning

👉 Example:

• “difficulty with visual closure impacting ability to complete puzzles”

🤸 7. Sensory / Regulation Phrases

• Benefits from proprioceptive input

• Improved regulation with deep pressure

• Decreased tolerance for visual/auditory input

• Seeks movement (vestibular input)

• Improved performance in low-stimulation environment

🤝 8. Social / Play Language

• Age-appropriate interaction

• Required cues for turn-taking

• Demonstrated increased need for control

• Engaged in parallel / cooperative play

• Initiated interaction with peers

🔗 9. FUNCTIONAL CONNECTIONS (don’t skip this)

👉 Always tie to function:

• …impacting participation in classroom tasks

• …impacting independence in play

• …impacting ability to follow multi-step directions

• …impacting peer interaction

⚡ 10. Make It SHORTER (your biggest growth area)

❌ Instead of:

“J had difficulty understanding the puzzle and needed a lot of help…”

✅ Say:

“J demonstrated decreased task comprehension during puzzle activity, requiring max cues.”

🧭 11. End of Note (Plan Statement)

👉 Keep it simple:

• “Client will continue to benefit from skilled OT services to address ______.”

Examples:

• executive functioning

• attention to task

• visual-perceptual skills

• social participation

🚨 12. Quick Self-Check Before You Finish

Ask yourself:

• Did I include cueing level?

• Did I state the deficit clearly?

• Did I connect it to function?

• Could I say this in fewer words?