OT Evaluation Note: Templates, Examples & How to Write One

What Is an OT Evaluation Note?

An OT evaluation note is the first formal document you create when a patient begins occupational therapy. It captures who the patient is, what they can and cannot do, and what you plan to work on together. Unlike a daily SOAP note — which records a single treatment session — the evaluation tells the whole story at once.

A complete evaluation includes four big pieces: the occupational profile (the patient's background, roles, and concerns), the analysis of occupational performance (your clinical reasoning about what is limiting function), the goals (what the patient will achieve), and the plan of care (how you will get there). Every section matters. Insurers look for each one, and missing any piece is one of the top reasons claims are denied.

Think of the evaluation as a contract between you, the patient, and the payer. It says: here is the problem, here is the evidence, and here is the plan. Everything you document after this note — daily SOAP notes, progress notes, and the discharge summary — should trace back to what you wrote here.

Structure of an OT Initial Evaluation

Most facilities use their own templates, but the core sections are the same everywhere. Here is the structure you should follow, regardless of setting or EHR.

1. 1Identifying information — Patient name, age, date of birth, diagnosis or ICD-10 code, referral source, and date of evaluation.
2. 2Occupational profile — Prior level of function, living situation (alone, with spouse, assisted living), work or school roles, daily routines, and the patient's stated concerns or goals.
3. 3Medical and surgical history — Relevant diagnoses, surgeries, medications, precautions, and contraindications. Include only what affects your treatment plan.
4. 4Objective findings — Range of motion (ROM), manual muscle testing (MMT), sensation, cognition, vision, functional performance on standardized tests, and any outcome measures you administered.
5. 5Analysis of occupational performance — This is your clinical reasoning. Connect the objective findings to the functional deficits. Explain why the patient cannot do what they need to do.
6. 6Goals — Long-term and short-term goals in SMART format. Goals should be functional and measurable.
7. 7Plan of care — Frequency and duration, planned interventions, equipment or adaptive devices, caregiver training needs, and discharge criteria.

Every section should be concise but complete. The goal is to give any therapist — or any auditor — enough information to understand the patient's situation without having to call you.

How to Write SMART Goals for OT

SMART goals are the standard in occupational therapy. They make your goals clear enough that anyone reading the chart can tell whether the patient met them. If a goal is vague, it is hard to measure — and if you cannot measure it, insurers may say the patient did not make progress.

SMART stands for Specific, Measurable, Achievable, Relevant, and Time-bound. Here is a quick breakdown.

Below are six example SMART goals from different practice settings. Notice that every goal names the task, the level of assistance, and the timeframe.

1. 1Adult outpatient: By 8 weeks, patient will independently don an overhead shirt within 3 minutes without adaptive equipment in 4 out of 5 trials.
2. 2Pediatric: By 12 weeks, child will cut a 6-inch straight line with scissors within 1/4 inch accuracy in 4 out of 5 trials.
3. 3SNF: By discharge (est. 2 weeks), patient will complete toilet transfer with standby assist using a grab bar in 5 out of 5 trials.
4. 4Home health: By 30 days, patient will independently prepare a simple cold meal using adaptive utensils with no more than 1 verbal cue.
5. 5Hand therapy: By 6 weeks, patient will achieve composite fist grip strength of 25 lbs (currently 12 lbs) as measured by dynamometer.
6. 6School-based: By end of IEP year, student will write first and last name legibly on grade-level lined paper in 4 out of 5 trials.

CPT Codes for OT Evaluations

Choosing the right CPT code for your evaluation is important for correct reimbursement and compliance. The code you pick should match the complexity of your clinical decision-making, not just how long the session lasted.

The key factors that determine complexity are: (1) the number of occupational performance deficits, (2) the amount of clinical decision-making required, and (3) the presence of comorbidities that complicate the plan of care. Document all three clearly in your note so the code you bill is supported.

A common mistake is defaulting to 97167 for every evaluation. If the patient has a simple, isolated problem — like a single tendon repair with no other medical history — a low-complexity code (97165) is appropriate and honest. Upcoding puts your practice at risk during audits.

3 OT Evaluation Note Examples

Below are three full evaluation note examples from different practice settings. Each one follows the structure outlined above. Use these as templates and adjust the details for your patients.

Example 1: Adult Outpatient — Hand Therapy (Carpal Tunnel Release)

Example 2: Pediatric Clinic — Fine Motor and Visual Motor Delay

Example 3: Home Health — Post-Stroke

OT Re-Evaluation Notes

A re-evaluation is not the same as a progress note. It is a formal reassessment of the patient's status that leads to a decision: continue, modify, or end the plan of care. Medicare requires a re-evaluation at least every 30 calendar days or every 10 treatment visits, whichever comes first. Many private payers follow similar rules.

Your re-evaluation should include updated objective measurements (re-test any standardized assessments you used initially), a status report on each goal (met, partially met, not met, or revised), clinical justification for continued treatment or discharge, and any changes to the plan of care. Bill re-evaluations under CPT 97168.

Here is a brief re-evaluation example for the hand therapy patient from Example 1 above.

Common Evaluation Documentation Mistakes

Even experienced therapists make documentation errors that can lead to claim denials or audit problems. Here are the most common mistakes to avoid in your evaluation notes.

1. 1Vague goals — "Patient will improve hand function" is not measurable. Every goal needs a specific task, a measurable standard, and a timeframe.
2. 2Missing prior level of function — If you do not document what the patient could do before the injury or illness, the insurer has no baseline to measure progress against.
3. 3No functional connection — Listing ROM and strength numbers without explaining how those deficits affect daily activities. Always bridge the gap between impairments and function.
4. 4Wrong CPT complexity level — Billing 97167 for a straightforward evaluation invites audit scrutiny. Match the code to the actual complexity of clinical decision-making.
5. 5Forgetting to document medical necessity — The evaluation must clearly state why skilled OT services are needed. If it reads like the patient could do a home program on their own, the claim will be denied.

Let an AI Scribe Handle the Note

Writing a thorough evaluation note can take 30 minutes or more after the session is over. Augustun for occupational therapy listens to your evaluation session in real time and drafts a complete, structured note — occupational profile, objective findings, goals, and plan of care — before the patient leaves the room. You review, edit, and sign. It works with over 400 EHR systems and is fully HIPAA and GDPR compliant. Recordings are never stored. You keep full control of the final note.

Final Thoughts

A strong OT evaluation note does three things: it justifies the need for skilled care, it gives the patient a clear path forward, and it protects your practice from claim denials and audits. Take the time to document every section — occupational profile, objective findings, clinical reasoning, SMART goals, and plan of care. Use the right CPT code for the complexity of the case.

Once the evaluation is done, the documentation lifecycle continues with daily treatment notes, progress notes, and eventually a discharge summary. For a complete walkthrough of those note types, read our guide on OT progress notes and discharge.