As an occupational therapist, you help people do the things they want and need to do every day. But after you finish helping a child tie their shoes or teaching an older adult how to safely get dressed, you have one more important job. You must write a note about what you did. This is called OT documentation. It might feel like just paperwork. But good notes are very important. They show that your work helped the person. They also make sure you get paid by insurance. And they protect your license.

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Do not worry. You do not need fancy words to write a good OT note. In this blog, I will show you best ways to write notes. We will share examples from pediatrics, schools, skilled nursing, and home health. I will also give you a cheat sheet at the end. Let us start.

What Is Occupational Therapy Documentation?

Documentation is a written record of your work with a client. It shows what you saw, what you did, and how the client changed. Think of it as a diary of progress. Every note has a date, a signature, and your professional title (OTR/L, COTA).

Good notes protect you and your client. They prove you gave skilled care. They show the next therapist what to do. And they help insurance companies say yes to more visits. Without good notes, it is like you did nothing at all. That sounds harsh, but it is true.

The Main Types of OT Notes

You will write different notes for different places. A note for a school looks different from a note for a nursing home. But all notes share the same bones. You will learn four main types:

1. Initial Evaluation – The first time you meet the client. You test their skills and set goals.
2. Daily Note / SOAP Note – One session. What happened today.
3. Progress Note – Written every 10 visits or 30 days. Shows change over time.
4. Discharge Note – The last note. Summarizes everything and gives a plan for the future.

In this blog, we focus on daily SOAP notes because you write them most often.

Why OT Notes Matter (Even When You Are Tired)

You work hard all day. Writing a note is the last thing you want to do. But here is why you should care. A good note tells a story. It shows where the person started, what you did to help, and how they are better now.

Insurance companies read your notes. If your note does not show skilled care, they may not pay. Your boss reads your notes. If your note is not clear, they cannot prove your value. And other therapists read your notes. If you are sick and someone covers for you, they need to know what to do next.

So take a deep breath. You can write a great note in five minutes. Use simple words. Stick to the facts. And always show progress.

The Main Parts of an OT Note (SOAP Note Format)

Most OT notes use something called SOAP. That is an easy way to remember the four parts.

S = Subjective. This is what the person or their family tells you. For example, “My hand feels weak today.”

O = Objective. This is what you see and measure. For example, “Child held pencil for 2 minutes before stopping.”

A = Assessment. This is what you think about the session. Did they do better or worse than last time? Why?

P = Plan. This is what you will do next time. For example, “Next session, try a thicker pencil grip.”

Let us look at how this works in different places where OTs work.

Pediatric OT Notes (Clinic or Home-Based)

In pediatrics, you work with children. They may have trouble with handwriting, playing, or dressing. Your notes need to show what the child could not do before, and what they learned today.

Example Pediatric SOAP Note

S (Subjective): Mom said, “Leo cried when I gave him the scissors yesterday. He said they hurt his hand.”

O (Objective): Leo is 5 years old. Diagnosis: fine motor delay. Today, Leo sat at the table for 10 minutes. He used adapted loop scissors to cut a straight line. He completed 3 out of 5 cuts without help. His right hand had a weak grasp (2 out of 5 on muscle scale). He dropped the scissors twice.

A (Assessment): Leo made good effort today. He followed one-step directions like “open the scissors.” But his hand muscles get tired fast. He needs more hand strengthening before cutting shapes. Compared to last week, he cut 2 more inches without stopping. That is progress.

P (Plan): Next session, use play-doh to squeeze and roll for 5 minutes before cutting. Practice cutting thicker paper. Teach mom one hand game (spinning a small top) for home.

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Pediatric Tips

• Use the child’s name, not just “the client.”
• Write what the child actually did, not what you wished they did.
• Show progress by comparing to last week or last month.

School-Based OT Notes (Inside the Classroom)

School-based OT is different. You are not the main teacher. You help the child access their education. Your notes must connect to school goals, like writing, typing, or using the bathroom. You also write notes that teachers and parents can read.

Example School-Based SOAP Note

S (Subjective): Teacher said, “Mia refuses to write her spelling words. She throws the pencil.”

O (Objective): Mia is 7 years old, 2nd grade. IEP goal: write 3 sentences with 80% legibility. Today, during writing center, Mia used a weighted pencil. She wrote 2 sentences in 8 minutes. Letters were medium size (not too big or small). 4 out of 10 letters were reversed (b/d and p/q). She did not throw the pencil today. She asked for one break after 6 minutes.

A (Assessment): Mia is improving with the weighted pencil. She wrote one more sentence than last week. Reversals are still high. She needs more visual memory work. Her attention was good with the break option. She is using her self-regulation strategy (asking for break) without a meltdown. That is a big win.

P (Plan): Continue weighted pencil. Add a “letter hunt” worksheet for reversals. Give Mia a 2-minute break after 5 minutes of writing. Consult with teacher to try a slant board.

School-Based Tips

• Link everything back to the IEP goal.
• Write down exactly what help you gave (e.g., verbal prompt, physical help).
• Mention how the classroom environment was set up (lighting, noise, seating).

Skilled Nursing Facility (SNF) OT Notes (Working with Older Adults)

In skilled nursing, you help older adults after a surgery, stroke, or fall. They want to go home safely. Your notes need to show medical necessity. That means you prove that a nurse or aide cannot do what you do. Only an OT can do it.

Example Skilled Nursing SOAP Note

S (Subjective): Mrs. Jones said, “I am scared to take a shower by myself. I almost fell last week.”

O (Objective): Mrs. Jones is 82 years old. Diagnosis: right hip replacement, 2 weeks post-op. Today she sat on a shower chair. She used a long-handled sponge to wash her legs. She needed moderate help (50% assist) to stand and turn to wash her back. She followed 2-step safety commands. Her balance was fair (can sit without support but sways when reaching). Blood pressure stable. No falls.

A (Assessment): Mrs. Jones is motivated but fearful. Her upper body strength is good (4/5). Her standing balance is poor without a grab bar. She remembered all safety steps when I asked her to repeat them. Compared to last session, she needed less help (down from 75% assist to 50% assist). She is ready to practice standing at the sink for teeth brushing.

P (Plan): Next session, practice standing at sink for 2 minutes with grab bar. Teach her to use a non-slip mat. Continue shower training two times this week. Recommend bath bench for home.

Skilled Nursing Tips

• Use words like “moderate assist,” “minimal assist,” or “contact guard.” These show how much help you gave.
• Write numbers when you can. Example: “walked 20 feet with a walker.”
• Always mention safety. Falls are a big deal.

Home Health OT Notes (Inside the Patient’s Home)

Home health is unique. You see how the person lives. Maybe the bathtub is too high. Maybe the kitchen is cluttered. Your notes should show how you change the home environment to help the person be independent.

Example Home Health SOAP Note

S (Subjective): Mr. Lee said, “I cannot open my medicine bottles. My daughter helps me, but she only comes on Sundays.”

O (Objective): Mr. Lee is 74 years old. Diagnosis: osteoarthritis in both hands. Today I visited his home. I observed him try to open a child-proof pill bottle. He tried for 2 minutes, then gave up. Grip strength: right hand 4 pounds, left hand 3 pounds (normal is 15-20). He then used a simple easy-open bottle cap. He opened it in 5 seconds without pain.

A (Assessment): Mr. Lee is independent with daily tasks like eating and dressing. But he cannot manage his medications because of weak grip and child-proof caps. This is a safety risk. He learned how to use an easy-open cap in one try. He is a fast learner and very motivated to stay out of the hospital.

P (Plan): Call pharmacy to request non-child-proof caps for all his meds. Teach Mr. Lee a hand exercise using a soft ball (squeeze 10 times, twice a day). Next visit, check his pill organizer setup. Teach him to use a jar opener for the kitchen.

Home Health Tips

• Write down things you see in the home (rugs, pets, stairs, lighting).
• Mention family or caregivers if they are there.
• Show how you changed the environment, not just the person.

What Does “Skilled” Mean in OT Notes?

Insurance companies look for the word “skilled.” Skilled does not mean you are smart. It means you did something that a non-therapist cannot do. For example, a parent can help a child put on a jacket. But only an OT knows how to break that task into small steps, find the weak muscle, and teach a special trick.

Here are examples of skilled services:

• You choose a specific pencil grip after testing three different ones.
• You teach a person with stroke how to put on a shirt using only one hand.
• You change the height of a chair to fix a person’s sitting balance.

Unskilled things sound like this:

• “Helped patient walk.” (A nurse can do that.)
• “Reminded child to sit.” (A teacher can do that.)
• “Talked to patient.” (Anyone can do that.)

So in your note, always add why only you could do it. Example: “Used therapeutic handling to facilitate trunk rotation while reaching for a cup. This addresses core stability deficit noted on initial eval.”

A Cheat Sheet for Faster OT Notes

Keep this cheat sheet near your computer or clipboard. It will save you time.

Subjective (S) Quick Phrases

• “Patient reports…”
• “Family states…”
• “Caregiver said…”
• “Feeling: tired, motivated, scared, sore, happy.”

Objective (O) Quick Measurements

• Assist levels: Independent, Supervision, Minimal (25% help), Moderate (50%), Maximal (75%), Dependent
• Strength: 5/5 normal, 4/5 good, 3/5 fair, 2/5 poor, 1/5 trace
• Distance: 10 feet, 20 feet, across room
• Time: 2 minutes, 10 minutes, entire session
• Number of tries: 3 out of 5, 2 times, 0 times

Assessment (A) Sentence Starters

• “Patient demonstrated…”
• “Compared to last session…”
• “Barriers to progress include…”
• “Patient is making good/fair/minimal progress toward goal.”
• “Skilled OT was needed to…”

Plan (P) Common Next Steps

• “Continue with current plan.”
• “Increase difficulty to…”
• “Decrease prompts.”
• “Teach caregiver…”
• “Recommend follow up in 1 week.”
• “Discharge planning started.”

Pediatric/ School Cheat Sheet

• Use: “attention span,” “fine motor,” “visual motor,” “sensory break,” “handwriting legibility”
• Example: “Child attended for 4 minutes then needed redirection.”

Skilled Nursing Cheat Sheet

• Use: “bed mobility,” “transfer,” “grooming,” “toileting,” “safety awareness,” “fall risk”
• Example: “Needed moderate assist for sit-to-stand.”

Home Health Cheat Sheet

• Use: “home environment,” “adaptive equipment,” “caregiver training,” “bath safety,” “medication management”
• Example: “Removed throw rug to reduce fall risk.”

Three Common Mistakes and How to Fix Them

Mistake 1: Writing the Same Thing Every Day

Bad: “Patient did exercises. Patient did well.”
Good: “Patient did 10 shoulder presses with 2-pound weight. Increased from 5 reps last week.”

Mistake 2: Forgetting the “Skilled” Part

Bad: “Helped child with scissors.”
Good: “Used hand-over-hand guidance to teach proper scissor placement. Then faded to verbal cues only.”

Mistake 3: Not Linking to Goals

Bad: “Worked on balance.”
Good: “Worked on standing balance for long enough to pull up pants. This matches goal #3 for dressing.”

Putting It All Together (A Full OT Note Example)

Here is one full note that could work for many settings. Read it from top to bottom.

Date: April 2, 2026
Setting: Home Health
Visit number: 4 of 12

S: Mr. Kim said, “I fell last night trying to use the bathroom. I am scared now.”

O: Mr. Kim is 78 years old. Diagnosis: left weakness from stroke 3 weeks ago. Today I taught him to use a bedside commode. He needed moderate assist (50%) to stand from his bed. He used his right hand to hold the commode arm. He sat with supervision only. He remembered to call for help before standing. No falls occurred during session. Bedside commode placed 2 feet from bed.

A: Mr. Kim is at high risk for falls at night. He shows good learning with repetition. He followed safety steps after two demonstrations. Compared to last visit, he needed less help (down from 75% to 50%). Skilled OT was needed to teach proper transfer technique and to position the commode safely.

P: Next visit: teach night-time bathroom routine with a flashlight. Practice sit-to-stand from the commode 5 times. Order grab bar for bathroom wall. Reassess fall risk in 3 days.

Final Thoughts

Writing OT notes can feel like a hassle, sometimes, especially after a long day. But your note is the only thing that proves your work was skilled and necessary. Without a clear note, insurance might not pay, and the next therapist won’t know where to start. So just stick to the basics: write what the patient said, what you did and measured, what you think about their progress, and what you plan to do next. Use the cheat sheet when you feel stuck. Keep your words simple and true. You already have the skills. Now just write it down and move on to the next patient.

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