OCCUPATIONAL 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]