OT Progress Note Template and Drafting Workflow

A strong OT progress note must move beyond 'patient tolerated treatment well' to document specific functional changes. Key sections include the subjective report of the patient's experience, objective measurements (such as ROM or timed functional tasks), an assessment of how these results relate to the established goals, and a plan for the next session. Documentation should explicitly link the intervention provided to the functional outcome achieved, ensuring the medical necessity of continued therapy is clear.

Using an AI medical scribe removes the burden of recalling specific phrasing from a session hours after it ended. Instead of starting with a blank template, clinicians review a draft generated directly from the encounter recording. This allows the therapist to focus on the clinical assessment and the nuance of the patient's progress, using transcript citations to verify that the objective data in the note exactly matches what occurred during the visit.