Occupational Therapy Inpatient Treatment Note

Date of Service: [Date of service] (If visit was incomplete, document minutes delivered and reason.)
Patient: [Patient name]
Location/Setting: [acute care / LTACH / SNF / other inpatient unit]
Total Treatment Minutes: [Total billable minutes] (If session ended early, specify minutes per activity and clinical reason.)
Precautions/Restrictions: [Active precautions relevant to session] (Include weight-bearing status, lines/drains, isolation, fall risk, orthostatic precautions as applicable.)
Primary Focus: [Brief treatment focus tag] (2–5 words, e.g., self-care retraining, safe transfers, caregiver training.)

Subjective

[Patient self-reported concerns and goals for the session] (Use a direct quote only when it clarifies motivation, refusal, or discharge-critical preferences. If patient cannot provide subjective information, briefly state the reason.)

Pain: [Pain level, scale, and location] (Include timing relative to activity if relevant.)

Symptoms affecting participation: [Fatigue / dizziness / SOB / nausea / other as reported] (Omit if none reported.)

Caregiver input: [Relevant caregiver observations or goals] (Omit if caregiver not present or no relevant input.)

Objective

Functional tasks and interventions: [For each task: task name, assistance level, cue type and frequency, adaptive equipment used, safety/cognitive observations, skilled intervention provided, patient response, and any modifications due to medical status or performance barriers] (Document each functional task addressed; pair interventions with patient response.)

Physiologic response: [Vitals or symptoms that influenced clinical decision-making] (Include only when session was modified due to physiologic response; otherwise omit.)

Activity tolerance: [Time upright, rest breaks, distance, or other quantifiable measures] (Include strategies provided for pacing or energy conservation if applicable.)

Education/training provided: [Learner, content, method, and effectiveness] (Omit if no education or caregiver training occurred this session.)

Skilled reasoning: [Brief justification of clinical decisions requiring OT skill] (Include when significant task grading, medical instability requiring adaptation, or unexpected functional changes occurred.)

Assessment

[Clinical summary of patient response to treatment with measurable detail; progress toward goals addressed this session; limiting factors such as medical status, cognition, pain, or safety concerns; justification for continued skilled OT; discharge readiness interpretation if relevant including current assistance needs for safe ADL performance] (Avoid vague phrases like "tolerated well"; reference specific metrics or assistance levels.)

Plan

Next session focus: [Planned interventions and progression parameters] (Specify expected progression, environment changes, or equipment trials.)

Discharge planning: [Recommended discharge setting with rationale; DME needs and procurement status; remaining caregiver training needs] (Document specific unknowns if elements are pending.)

Interdisciplinary communication: [Team members updated and content communicated regarding safety, discharge barriers, or equipment] (Omit if no interdisciplinary communication occurred.)

Frequency: [Treatment frequency and duration] (Include rationale if deviating from plan of care.)