Occupational Therapy Progress Report (10th Visit/30-Day)

Document Type: Occupational Therapy Progress Report (10th Visit / 30-Day)

Reporting Period: [start date] to [end date] ([number] treatment visits)

Date Written: [date]

Patient: [name], DOB [date], MRN [number]

Rendering Clinician: [name, credentials (e.g., OTR/L)]

Primary Diagnosis/Reason for OT: [diagnosis or referral reason]

Precautions: [precautions if applicable / None identified]

Attendance: [visits completed] of [visits planned]; [cancellations/no-shows if relevant] (If OTA provided care, briefly note clinician involvement.)

Subjective

[Patient-reported functional changes since last report] (Summarize ADL/IADL status, symptoms, home program adherence, and current priorities. Use direct quotes only for clinically salient statements. If patient cannot report, state source or "Unable to report (reason: ___).")

Objective

Measurements:

Measure	Baseline (value, date, conditions)	Current (value, date, conditions)	Change
[measure name]	[baseline value, date; conditions]	[current value, date; conditions]	[delta]

(Add rows as needed. For each measure, include baseline and current values with dates and conditions such as assist level or device. Do not infer improvement without measured support. If not assessed: "Not assessed this period (reason: ___).")

Interventions This Period: [Summary of skilled OT interventions by problem area] (Emphasize skilled components: clinical reasoning, task grading, cueing strategies, safety judgment. Include caregiver education and home program updates as applicable.)

Goal Status

(Document each active goal using stable identifiers. Repeat structure for each goal.)

Goal [identifier]: [measurable, occupation-based goal statement]

• Baseline: [value, date]
• Current: [value, date]
• Status: [Met / Partially Met / Not Met / Revised / Discontinued]
• Evidence: [objective data or task performance supporting status]
• Barriers/Facilitators: [factors affecting progress; if not progressing, state why and planned changes] (If revised or discontinued, document reason and replacement goal identifier.)

(Add additional goals as needed.)

Assessment & Plan

Assessment: [Synthesis of objective trends and overall functional progress] (State whether patient is making expected progress; if not, explain why. Provide skilled rationale for continued OT or discharge. For rehabilitative care, indicate expectation of further improvement. For maintenance, explain why skilled OT is required. Avoid conclusory statements without objective support. Must be authored by OT.)

Plan: [continue as written / revise]; [frequency/duration for next period]; [intervention focus]; [home program updates] (If POC changes require certification: "POC revision requires recertification; sent [date] or pending.")

Coordination: [Communication with referring provider, case manager, or other disciplines] (Include only if coordination occurred during this period.)

Signature

[Clinician signature, credentials, date/time]