An occupational therapy progress note reviews a period of care: progress on each goal, changes in assist levels, and the plan for what comes next. Copy the free template, see two filled examples, and check how to show change in function.
Blank occupational therapy progress note template
FreeOCCUPATIONAL THERAPY PROGRESS NOTE Client: [Name] Date of birth: [Date] Date of note: [Date] Review period: [First and last session covered] Sessions: [Sessions attended and missed in this period] Diagnosis: [Medical diagnosis and occupational performance problem] Therapist: [Name, credentials] CLIENT REPORT Change in daily life: [What the client can do now that they couldn't before, and what is still hard] Self-rating: [Client's rating of performance and satisfaction on priority activities, then and now] Strategies in use: [Home program, equipment, and strategies the client uses, and how often] FUNCTIONAL STATUS Activity 1: [Task] | Then [assist level, cues, equipment] | Now [assist level, cues, equipment] Activity 2: [Task] | Then [assist level, cues, equipment] | Now [assist level, cues, equipment] Activity 3: [Task] | Then [assist level, cues, equipment] | Now [assist level, cues, equipment] Re-assessment: [Measures repeated, with the earlier and current scores] GOAL REVIEW Goal 1: [Goal] | Status [met, progressing, not met, or discontinued] | Evidence [what shows it] Goal 2: [Goal] | Status [met, progressing, not met, or discontinued] | Evidence [what shows it] Goal 3: [Goal] | Status [met, progressing, not met, or discontinued] | Evidence [what shows it] ANALYSIS What is working: [Interventions, strategies, or supports that made the difference] What is limiting: [Client factors, performance skills, or context still in the way] Safety: [Changes in safety awareness or risk] UPDATED PLAN Goals for the next period: [New or revised goals, measurable, with a time frame] Approach: [Changes to interventions] Equipment and environment: [New equipment, home or work changes] Frequency and duration: [Sessions per week and number of weeks, or plan to discharge] Shared with: [Client, family, referrer, or team] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient hand therapy, 6-week review
52-year-old cook, 8 weeks after a right open carpal tunnel release, in therapy since week 2. Night numbness gone since the second week. Pain at the base of the palm when pushing up from a chair or gripping heavy pans, 3/10, was 6/10. Back at work on reduced hours and light duties. Rates lifting pans at work 5/10 for performance and 4/10 for satisfaction, up from 2 and 2. Does scar massage and the home program daily.
Lifting a full saucepan: then unable; now independent with both hands. Chopping vegetables: then 5 minutes before pain; now 20 minutes with a built-up knife handle. Opening jars: then needed help; now independent with a jar opener. Re-assessment: right grip 18 kg (40 lb), was 8 kg (18 lb) at week 4; left 30 kg (66 lb). QuickDASH 34, was 61. Monofilament testing normal in the median nerve area. Scar soft; tender at the base of the palm with firm pressure.
Goal 1, independent with scar care and desensitization: met; done daily without prompts. Goal 2, right grip 60% of the left by week 8: met, 18 of 30 kg. Goal 3, return to full duties: progressing; still on light duties, and lifting heavy stockpots is painful. Goal 4, QuickDASH below 30: progressing, now 34.
Good recovery. Nerve symptoms have resolved and grip is improving steadily. Pain at the base of the palm with heavy gripping is the main barrier to full duties. Graded strengthening and work simulation have helped most, and the adapted knife handle reduces strain at work. No safety concerns.
Goals for 4 weeks: lift a 10 kg (22 lb) stockpot with both hands at work with pain 2/10 or less; complete a full shift with planned breaks; QuickDASH below 20. Approach: progress grip and wrist strengthening; work simulation with heavier loads and longer tasks; pacing and task rotation at work. Equipment: padded gloves for heavy lifting. Once a week for 4 weeks, then discharge to a home program. Shared with her surgeon and family physician.
Outpatient neurological rehab, 6-week review
44-year-old woman with relapsing-remitting multiple sclerosis, 6 weeks into a fatigue management program. Works in an office 4 days a week. Takes a planned 20-minute rest after lunch, and most days no longer needs a 2-hour nap after work. Cooks dinner 4 nights a week, sitting to prepare food; was ordering in most nights. Still too tired for her daughter’s weekend games. Heat makes her fatigue worse. Rates cooking 6/10 for performance and 6/10 for satisfaction, up from 3 and 2. No new weakness, vision changes, or bladder changes.
Cooking a weeknight meal: then unable most nights, lying down after 10 minutes standing; now independent, seated on a perching stool, with the meal planned and supplies gathered first. Showering: then 30 minutes of rest afterward; now uses a shower chair and lukewarm water and rests 5 minutes. After work: then a 2-hour nap 4 days a week; now 1 day a week. Re-assessment: Modified Fatigue Impact Scale 38, was 52. Activity diary: planned rest breaks taken on 5 of 7 days.
Goal 1, plan each week with an activity diary and rest breaks: met. Goal 2, cook dinner 4 nights a week using energy conservation strategies: met. Goal 3, attend one of her daughter’s weekend games each week: progressing, 2 in 6 weeks. Goal 4, return to a 5-day work week: discontinued at her request; she and her employer have agreed on a 4-day week.
Planning, pacing, sitting for tasks, and keeping cool are working. Fatigue still limits weekend and family time, partly because work uses most of her energy. Summer heat is a factor. Safety: no falls; uses the shower chair every time.
Goals for 6 weeks: attend one weekend game each week with a rest plan; Modified Fatigue Impact Scale 30 or lower; independent with a written plan for hot weather. Approach: weekend planning, cooling strategies, and a workstation review. Equipment: information on cooling vests given. Every 2 weeks for 6 weeks, then discharge with a home plan. Advised to contact her MS team about any new or worsening symptoms lasting more than 24 hours. Shared with her neurologist.
The client’s view of change: what daily activities are easier, what is still hard, and how satisfied they are.
Avoid: Recording only symptoms. The client’s view of their own function is the point here.
Key activities side by side: the assist level, cues, and equipment then and now.
Avoid: Changing how you rate assist levels between notes. Use the same definitions each time.
Each goal from the plan, with a status and the evidence behind it.
Avoid: A status with no evidence. Say what you saw or measured.
Your reasoning about why progress is or isn’t happening, and what that means for safety.
Avoid: Putting slow progress down to the client without looking at the plan, the context, or the barriers.
What changes for the next period, or the plan to discharge.
Avoid: Renewing the same plan when goals are met. Set new ones, or plan the discharge.
Write the earlier level beside the current one for each activity. “Min assist” alone doesn’t show change.
Client-rated performance and satisfaction show whether the changes matter to the person living with them.
If a goal no longer fits, say why, and whether the client agreed.
When goals are met or progress stalls, the plan should change. Say what will be different.
Record any change in safety: falls, new equipment and whether it is used, or new risks at home or work.
Vero Scribe writes the progress note in your template from the session conversation, with the client’s consent, or from your dictation. You review and edit it, then copy it into your EMR or export it to PDF or Word for the referrer.
The review period and sessions attended, the client’s report, key activities with assist levels then and now, repeated measures, the status of each goal with evidence, your analysis, and the updated plan.
At the interval your organization, regulator, or payer sets, and whenever the client’s status, goals, or plan change. Session notes go in between.
Compare the same activities with the same assist level definitions over time, note fewer cues or less equipment, repeat standardized measures, and record the client’s own rating of performance and satisfaction.
Give the current level, the reason, and what you will change: the approach, the time frame, or the goal itself. If the goal no longer fits the client’s priorities, discontinue it and say why.
Yes. Copy it, or download it as a Word or text file. No account needed.
Function-focused session note with ADLs, IADLs, assist levels, cues, fine motor, and safety.
Occupational profile, environment, ADL and IADL performance, named assessments, goals, and plan.
Worked OT notes, with assistance and cueing examples.
A step-by-step workflow, examples, and a quality checklist.
Draft progress notes in your template, then edit and export them.
Notes, documents, and follow-up in one workspace.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
No credit card required. 10 free actions every month.