Occupational Therapy Progress Note Example

A strong occupational therapy progress note must move beyond simple activity lists to demonstrate medical necessity. It should clearly detail the patient's current level of function compared to their baseline, specifically documenting the 'skilled' nature of the intervention. Key sections include the subjective report of functional limitations, objective measurements of ROM or grip strength, and an assessment that links these findings to the achievement of specific, measurable goals for Activities of Daily Living (ADLs).

Using Aduvera to draft these notes ensures that the nuanced details of a therapy session—such as the specific prompts provided or the patient's response to a modified tool—are not lost to memory fade. Instead of recalling the session hours later, clinicians review a high-fidelity draft generated from the actual encounter. This allows the therapist to focus on refining the clinical assessment and verifying the accuracy of the functional gains before finalizing the documentation.