13 min read

OT Progress Notes & Discharge Summaries: Templates & Examples

Dr. Medeline Yost

Chief Medical Officer, Augustun

Published July 4, 2026

Updated July 4, 2026

On this page

What Is an OT Progress Note?
When Are OT Progress Notes Required?
Structure of an OT Progress Note
KX Modifier and OT Documentation
3 OT Progress Note Examples
What Is an OT Discharge Summary?
Structure of an OT Discharge Summary
2 OT Discharge Summary Examples
What Auditors Look For in Progress Notes and Discharge Summaries
Let an AI Scribe Handle the Note
Final Thoughts
FAQ

Your daily SOAP notes capture what happened in each session. But progress notes and discharge summaries tell the bigger story. They answer the questions payers and auditors really care about: Is this patient getting better? Is continued OT still needed? Did the episode of care accomplish what it was supposed to? If you cannot answer those questions clearly, you risk denials, recoupments, and failed audits.

Medicare requires a progress note every 10 treatment visits or 30 calendar days — whichever comes first. A discharge summary is required at the end of every episode of care. Both documents must show measurable change and skilled reasoning. They are not optional, and they are not just a box to check. For a broader look at OT note types, see our OT documentation guide and OT evaluation note guide.

In this guide, you will get clear templates, real-world examples for SNF, outpatient, and home health, and a checklist of what auditors look for. Let us get started.

What Is an OT Progress Note?

A progress note is not the same as a daily treatment note. A daily note describes one session. A progress note summarizes a period of care — usually 10 visits or 30 days. It pulls back and asks: How has this patient changed since the last progress note or the initial evaluation?

Think of it as a report card. You update goal status, compare objective measurements from admission (or the last reporting period) to now, and explain why the patient still needs skilled OT — or why they are ready for discharge. Without a progress note, a payer has no way to know whether your treatment is working.

When Are OT Progress Notes Required?

The timing depends on the payer. Here is a quick reference:

Payer	Frequency Requirement
Medicare Part B	Every 10 treatment visits or 30 calendar days (whichever comes first)
Medicaid	Varies by state — typically every 30 days
Private Insurance	Typically every 30 days or as requested by the plan
Workers' Compensation	Varies by state — often every 30 days

For Medicare, the progress note is also the place where you document justification for services above the KX modifier threshold. If your patient's charges are approaching or exceeding that threshold, your progress note must include explicit medical necessity language. We cover that in detail below.

Structure of an OT Progress Note

Every progress note should include these elements, regardless of setting:

1Dates of service covered — the reporting period (e.g., 06/01/2026–06/30/2026)
2Current diagnoses — ICD-10 codes and relevant medical history
3Treatment provided during the period — brief summary of interventions and frequency
4Objective measurements — admission (or last report) vs. current scores, ROM, strength, FIM, etc.
5Goal status — each goal marked as met, progressing, not met, or revised
6Justification for continued skilled OT — why the patient still needs you (not an aide, not a home program alone)
7Updated plan of care — frequency, duration, any new goals or interventions
8Therapist signature and credentials — OTR/L or COTA with co-signature as required

KX Modifier and OT Documentation

Medicare sets a therapy cap threshold each year. When a patient's OT charges exceed that threshold, you must add the KX modifier to your claims. The KX modifier is your attestation that services above the cap are medically necessary and that your documentation supports that claim.

What does that mean for your progress notes? It means you need to be very specific. You must explain why the patient has not yet met their goals, why continued skilled intervention (not maintenance) is needed, and what functional outcomes you expect in the next reporting period. Vague language like "patient is making progress" is not enough.

Key Tip: KX Modifier Documentation

If you are billing above the KX threshold, every progress note must explicitly state why continued OT is medically necessary and why the patient has not yet met goals. Document the skilled nature of your interventions and the complexity that prevents the patient from progressing with a home program alone.

3 OT Progress Note Examples

Example 1: Skilled Nursing Facility (SNF)

OT Progress Note — SNF

Reporting Period: 06/17/2026–07/01/2026 (10 treatment sessions)
Diagnosis & Background: 82-year-old female, s/p right total hip replacement (06/15/2026). PMH: osteoarthritis, hypertension, mild cognitive impairment. Prior level of function: independent in all ADLs, lived alone in single-story home.
Treatment Summary: OT provided 5x/week for 2 weeks. Interventions included ADL retraining (dressing, bathing, toileting) with hip precaution education, transfer training (bed, toilet, tub), adaptive equipment training (long-handled reacher, sock aid, raised toilet seat), and progressive functional mobility tasks.
Objective Progress: Transfers — FIM admission: 2 (maximal assist) → current: 5 (supervision). Dressing lower body — FIM admission: 1 (total assist) → current: 4 (minimal assist with adaptive equipment). Bathing — FIM admission: 2 (maximal assist) → current: 4 (minimal assist, requires grab bar setup). Toileting — FIM admission: 3 (moderate assist) → current: 5 (supervision).
Goal Status: 1. Transfer bed/chair with supervision — MET. 2. Don/doff lower body clothing with adaptive equipment and minimal assist — MET. 3. Bathe with supervision using tub bench and grab bars — IN PROGRESS (currently minimal assist for lower body washing). 4. Toilet with modified independence — IN PROGRESS (supervision level, needs verbal cues for hip precautions). 5. Prepare simple meal standing 10 min — REVISED (patient reports pain at 7 min standing; revised to 8 min as interim goal).
Justification for Continued Care: Patient demonstrates consistent improvement but has not yet achieved safe independence in bathing and toileting. Mild cognitive impairment requires repeated cueing for hip precautions, which poses a fall risk if discontinued prematurely. Skilled OT is needed to upgrade bathing to supervision level, reinforce precaution adherence, and ensure safe discharge home where patient will live alone.
Updated Plan: Continue OT 5x/week for 1 additional week. Focus on bathing independence with tub bench, standing tolerance for kitchen tasks, and caregiver training for niece (weekend visitor). Anticipated discharge to home within 7–10 days.

Example 2: Outpatient Hand Therapy

OT Progress Note — Outpatient Hand Therapy

Reporting Period: 06/03/2026–07/01/2026 (8 treatment sessions, 2x/week)
Diagnosis & Background: 45-year-old male, s/p right distal radius fracture with ORIF (05/06/2026). Dominant hand. Occupation: carpenter. Cleared for active ROM at 4 weeks post-op, resistive exercise at 6 weeks.
Treatment Summary: OT provided 2x/week for 4 weeks. Interventions included AROM/PROM exercises for wrist and forearm, edema management (retrograde massage, compression glove), scar mobilization, progressive grip strengthening (therapy putty, hand dynamometer), and functional task practice (tool gripping, turning screwdriver, carrying objects).
Objective Progress: Wrist flexion — admission: 25° → current: 52°. Wrist extension — admission: 15° → current: 40°. Forearm supination — admission: 40° → current: 68°. Forearm pronation — admission: 55° → current: 72°. Grip strength (Jamar, position 2) — admission: 18 lbs → current: 42 lbs (uninvolved hand: 95 lbs). Edema (circumferential wrist) — admission: 19.2 cm → current: 17.8 cm (uninvolved: 17.5 cm).
Goal Status: 1. Wrist flexion ≥ 60° — IN PROGRESS (currently 52°, improving ~7°/week). 2. Wrist extension ≥ 50° — IN PROGRESS (currently 40°). 3. Grip strength ≥ 70 lbs — IN PROGRESS (currently 42 lbs, 44% of uninvolved). 4. Edema within 0.5 cm of uninvolved — MET (17.8 cm vs. 17.5 cm). 5. Return to full work duties — NOT YET ADDRESSED (requires grip ≥ 70 lbs and full ROM).
Justification for Continued Care: Patient shows steady gains in ROM and strength but remains significantly below functional thresholds for return to work as a carpenter. Grip at 44% of uninvolved is unsafe for power tool use. Continued skilled OT is needed for progressive resistive exercise, joint mobilization to address capsular tightness in extension, and work simulation tasks. Patient cannot safely perform these activities independently due to risk of re-injury.
Updated Plan: Continue OT 2x/week for 4 more weeks. Add work simulation tasks (hammer grip, sustained grasp, overhead reaching with load). Begin resistive forearm pronation/supination. Re-assess at visit 16 for potential work hardening referral.

Example 3: Home Health

OT Progress Note — Home Health

Reporting Period: 06/10/2026–07/01/2026 (6 treatment sessions, 2x/week)
Diagnosis & Background: 68-year-old female, s/p bilateral total knee replacement (06/03/2026). PMH: type 2 diabetes, obesity (BMI 34). Lives with spouse in two-story home. Prior level: independent, active community member.
Treatment Summary: OT provided 2x/week for 3 weeks in the home. Interventions included lower body ADL retraining (dressing, bathing, toileting), kitchen task training (meal prep with energy conservation), adaptive equipment training (reacher, sock aid, tub bench), caregiver training with spouse (safe guarding techniques), and home safety assessment with recommendations.
Objective Progress: Bathing — admission: moderate assist for lower body → current: supervision with tub bench. Dressing lower body — admission: maximal assist → current: modified independent with reacher and sock aid. Kitchen tasks (standing tolerance) — admission: 3 minutes → current: 10 minutes with rest breaks. Stair negotiation — admission: not attempted → current: 1 flight with rail and step-to pattern (supervision).
Goal Status: 1. Upper body dressing independently — MET (achieved session 3). 2. Lower body dressing with adaptive equipment, modified independent — IN PROGRESS (currently mod-I but reports difficulty with socks on swollen days). 3. Bathe independently with tub bench — IN PROGRESS (supervision level; needs standby for tub transfer on high-pain days). 4. Prepare simple meal standing ≥ 15 min — IN PROGRESS (currently 10 min). 5. Caregiver demonstrates safe guarding for stairs — MET (spouse return-demonstrated session 5).
Justification for Continued Care: Patient is progressing well but has not achieved independence in bathing or meal prep. Bilateral procedure and elevated BMI create higher fall risk during tub transfers. Diabetes-related edema fluctuations affect lower body dressing on some days. Skilled OT is needed to progress bathing to independence, build standing tolerance for community reentry, and provide problem-solving strategies for high-edema days.
Updated Plan: Reduce frequency to 1x/week for 3 weeks. Focus on bathing independence, meal prep with energy conservation, and community reentry planning (grocery store, car transfers). Reassess for discharge at visit 9.

What Is an OT Discharge Summary?

A discharge summary closes the episode of care. It is required every time a patient ends OT services — whether they met all goals, moved away, declined further treatment, or lost insurance coverage. Unlike a progress note that looks at one reporting period, the discharge summary covers the entire treatment episode from start to finish.

The most important element is the comparison between admission and discharge functional status. Payers and auditors want to see a clear before-and-after picture. If the patient improved, show it with numbers. If they did not, explain why and what alternative plan you recommended.

Structure of an OT Discharge Summary

A complete discharge summary should include:

1Dates of service — first visit to last visit
2Total number of visits — actual sessions attended
3Diagnoses — ICD-10 codes treated
4Summary of interventions — what you did across the episode (not session-by-session)
5Admission vs. discharge functional status — side-by-side comparison with objective measures
6Goals achieved vs. not achieved — clearly list each goal and its final status
7Reason for discharge — goals met, patient declined, insurance ended, moved, physician order, etc.
8Home program or follow-up recommendations — exercises, precautions, when to seek care
9Equipment provided — any DME ordered or recommended
10Therapist signature and credentials — OTR/L or COTA with co-signature

2 OT Discharge Summary Examples

Example 1: SNF to Home Discharge

OT Discharge Summary — SNF

Episode Summary: 82-year-old female, s/p right total hip replacement (06/15/2026). OT episode: 06/17/2026–07/08/2026. Total visits: 15. Treatment frequency: 5x/week for 3 weeks. Interventions: ADL retraining with hip precautions, transfer training, adaptive equipment training, standing tolerance and kitchen tasks, caregiver training with niece.
Admission vs. Discharge Status: Transfers (bed/chair/toilet) — Admission FIM: 2 (maximal assist) → Discharge FIM: 6 (modified independent). Lower body dressing — Admission FIM: 1 (total assist) → Discharge FIM: 6 (modified independent with adaptive equipment). Bathing — Admission FIM: 2 (maximal assist) → Discharge FIM: 6 (modified independent with tub bench and grab bars). Toileting — Admission FIM: 3 (moderate assist) → Discharge FIM: 7 (independent). Meal preparation — Admission: unable to stand > 2 min → Discharge: prepares simple meals standing 12 min with rest break.
Goals Achieved: 1. Transfer bed/chair with modified independence — MET. 2. Don/doff lower body clothing with adaptive equipment, modified independent — MET. 3. Bathe with modified independence using tub bench — MET. 4. Toilet independently — MET (exceeded goal). 5. Prepare simple meal standing 10 min — MET (achieved 12 min).
Reason for Discharge: All goals met. Patient safe for discharge to home. Demonstrates consistent adherence to hip precautions without cueing.
Recommendations: Home exercise program provided (hip strengthening, standing balance). Adaptive equipment sent home: long-handled reacher, sock aid, raised toilet seat, tub bench. Niece trained in safe guarding for community outings. Recommend outpatient OT referral if functional plateau reached or new limitations emerge. Follow up with orthopedic surgeon 07/15/2026.

Example 2: Outpatient Hand Therapy Discharge

OT Discharge Summary — Outpatient Hand Therapy

Episode Summary: 45-year-old male, s/p right distal radius fracture with ORIF (05/06/2026). OT episode: 06/03/2026–07/29/2026. Total visits: 16 (2x/week for 8 weeks). Interventions: AROM/PROM, joint mobilization, edema management, scar mobilization, progressive resistive exercise, functional grip training, work simulation tasks (hammer use, sustained grasp, power tool gripping).
Admission vs. Discharge Status: Wrist flexion — Admission: 25° → Discharge: 68° (normal: 80°, 85% of normal). Wrist extension — Admission: 15° → Discharge: 55° (normal: 70°, 79% of normal). Forearm supination — Admission: 40° → Discharge: 80° (normal: 85°, 94% of normal). Forearm pronation — Admission: 55° → Discharge: 78° (normal: 80°, 98% of normal). Grip strength — Admission: 18 lbs → Discharge: 78 lbs (uninvolved: 95 lbs, 82% of uninvolved). Edema — resolved (within normal limits bilaterally).
Goals Achieved: 1. Wrist flexion ≥ 60° — MET (achieved 68°). 2. Wrist extension ≥ 50° — MET (achieved 55°). 3. Grip strength ≥ 70 lbs — MET (achieved 78 lbs). 4. Edema within 0.5 cm of uninvolved — MET. 5. Return to full work duties — PARTIALLY MET (cleared for full duties; employer restricting overhead work > 30 min pending follow-up).
Reason for Discharge: 4 of 5 goals fully met. Functional ROM and grip strength sufficient for return to work as carpenter. Patient independent with home exercise program. Physician cleared for full activity.
Recommendations: Home exercise program provided (wrist stretching, grip strengthening with therapy putty, forearm resistance band exercises). Continue HEP daily for 4 weeks, then 3x/week ongoing. Return to OT PRN if regression in ROM or strength, or if new symptoms develop. Follow up with orthopedic surgeon for hardware evaluation at 6 months post-op.

What Auditors Look For in Progress Notes and Discharge Summaries

If your notes get pulled for a post-payment review or a RAC audit, here is what reviewers flag:

Copy-pasted notes — identical language across multiple reporting periods suggests no real reassessment occurred
Missing goal status updates — every goal must be addressed as met, progressing, not met, or revised
No functional outcome comparison — if you cannot show admission vs. current data side by side, the note fails
Missing medical necessity language — especially above the KX threshold, you must explicitly state why skilled OT is still required
Notes not signed within required timeframe — most payers require signature within 24–48 hours of the reporting period end
No discharge summary on file — missing discharge documentation triggers automatic recoupment in some jurisdictions
Vague or subjective language without objective support — phrases like "patient is doing better" without measurements do not meet standards

Let an AI Scribe Handle the Note

Writing progress notes and discharge summaries takes time — often 15 to 20 minutes per patient when you include the data comparison and medical necessity language. Multiply that by your caseload and it adds up fast.

Augustun listens to your sessions and generates structured notes that include goal tracking, objective comparisons, and compliance-ready language. It works with over 400 EHRs, so notes flow directly into your system. You focus on the patient. The AI handles the documentation.

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Final Thoughts

Progress notes and discharge summaries are where your clinical reasoning lives. They prove your care was skilled, necessary, and effective. A strong progress note keeps authorizations flowing. A solid discharge summary protects you if an auditor comes knocking years later.

Start with the templates above and adapt them to your setting. For more on evaluations, see our OT evaluation note guide. And if you are looking for a faster way to get all of this done, check out our guide to the best AI scribe for occupational therapy.

Frequently asked questions

How often are OT progress notes required for Medicare?

Medicare requires an OT progress note every 10 treatment visits or every 30 calendar days, whichever comes first. This applies to both Part A (SNF) and Part B (outpatient) settings. The note must include objective data, goal status, and justification for continued care.

What is the KX modifier in occupational therapy?

The KX modifier is added to Medicare claims when a patient's therapy charges exceed the annual therapy cap threshold. By using the KX modifier, the therapist attests that continued services are medically necessary and that documentation in the medical record supports that claim. Your progress notes must explicitly justify why services above the threshold are needed.

What should an OT discharge summary include?

A discharge summary should include dates of service, total visits, diagnoses treated, a summary of interventions, admission vs. discharge functional status comparison with objective measurements, goals achieved vs. not achieved, reason for discharge, home program recommendations, any equipment provided, and the therapist's signature with credentials.

How do I show functional progress in a progress note?

Use objective measurements compared side by side — admission scores vs. current scores. This can include FIM scores, ROM measurements, grip strength, timed functional tasks, or standardized assessments. Avoid subjective statements like "patient is improving" without data to support the claim.

Can an AI scribe write OT progress notes?

Yes. AI scribes like Augustun can generate structured progress notes from your session recordings. The AI captures objective data, updates goal status, and includes medical necessity language. You review and sign the note. This can save 15–20 minutes per progress note while improving consistency and compliance.