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Occupational Therapy · Templates
Occupational therapy note template
Built for occupational therapy visits where occupational profile, ADL/IADL performance, skilled interventions, and functional goals need a clear, therapist-usable note.
Template content
Copy or download, then paste into Wavo under My Templates.
Occupational Therapy Note Visit Context - Visit type (evaluation / progress / re-evaluation / discharge) and treating diagnoses. - Precautions and relevant medical updates since last visit. Occupational Profile / Subjective - Patient-reported performance in ADLs/IADLs, work, school, or leisure. - Pain, sensory symptoms, fatigue, and perceived barriers/successes since last session. - Patient priorities and goals for today's session. Objective / Performance - Observed ADL/IADL performance, UE ROM/strength/coordination/sensation, edema, fine motor measures, and standardized assessments as performed. - Adaptive equipment or orthosis status. Interventions - Skilled OT interventions provided (ADL retraining, therapeutic activity/exercise, neuromotor re-ed, sensory strategies, cognitive strategies, orthosis management, education). - Level of cueing/assistance and grading used. Response - Patient response to interventions, tolerance, and carryover of strategies/HEP. Assessment - Progress toward goals; remaining impairments limiting occupational performance. - Clinical rationale for ongoing skilled OT if continued. Plan - Next-session focus, HEP updates, equipment recommendations, frequency, and coordination with care team.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Centers occupations and ADLs rather than a generic medical SOAP default.
- Makes skilled intervention and patient response explicit for continuity and payers.
- Supports UE ortho, neuro, and general outpatient OT workflows.
- Pairs with PT and SLP templates for multidisciplinary rehab teams.
- 1Outpatient OT progress notes and evaluations
- 2Upper-extremity and hand therapy visits
- 3ADL-focused neurologic rehab sessions
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Visit Context OT progress visit #6 for right distal radius ORIF (POD 28). Precautions: no heavy lifting; progressive ROM per protocol. Subjective Pain 2/10 at rest, 4/10 with gripping. Difficulty buttoning shirts and opening jars. Completing HEP most days. Goal: return to cooking and keyboarding at work. Objective Wrist flexion 40°, extension 35°, supination 60°. Grip dynamometry 18 lb (L 52 lb). Edema mild. Buttoning: moderate difficulty with compensatory patterns. Interventions Skilled ADL retraining for fastening and jar opening with adaptive strategies; AROM/PROM wrist/forearm; putty and fine-motor graded activities; edema massage education. Minimal verbal cues after demo. Response Tolerated well; grip fatigue after 10 min, recovered with rest. Demonstrated improved buttoning with button hook trial. Assessment Improving wrist mobility and fine motor; still below functional grip for meal prep and full work duties. Continued skilled OT indicated for ADL independence and strengthening. Plan Continue OT 1–2×/week. Progress strengthening as pain allows; advance dressing independence without adaptive aid. HEP updated. Recheck grip/ROM next visit; coordinate with hand surgeon at 6-week f/u.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.