OT Progress Note Example and Drafting Guide

A strong OT progress note must move beyond 'patient tolerated treatment well' to document specific functional changes. It should include objective data on ADL performance, the specific therapeutic activities used to address deficits, and a clear comparison between the current status and the baseline established in the initial evaluation. Key sections typically include the subjective report of the patient, objective measurements of range of motion or grip strength, and an assessment of how these metrics impact the patient's ability to perform daily tasks.

Using Aduvera to draft these notes eliminates the need to recall specific measurements or patient quotes from memory hours after the session. The AI scribe captures the encounter in real-time, allowing the clinician to focus on the patient while the system organizes the data into a structured format. By reviewing transcript-backed citations, therapists can ensure that the documented progress is an accurate reflection of the session before the note is finalized for the EHR.