OTA Supervision/Co-Signature Note

Patient: [name, DOB, MRN per facility standard]

Date of Supervision: [date]

Supervising OT: [name, credentials]

OTA: [name, credentials]

Setting: [outpatient / home health / SNF / acute care / other]

(This note documents OT supervisory oversight. Do not imply direct OT treatment unless the OT actually treated or observed the client.)

Supervision Event

Event Type: [chart review/co-sign / supervisory contact / supervisory visit with client present / POC modification / discharge concurrence / other]

Method: [in-person / phone / telehealth / chart review / team conference]

Documents Reviewed: [OTA document type(s) and date(s) of service] (If documentation unavailable, state explicitly with follow-up plan.)

Clinical Oversight Summary

Information Source: [documents reviewed and dates, discussions with OTA and dates]

Client Status: [response to intervention, functional progress, key clinical findings] (Use objective, measure-based language. Summarize findings relevant to supervision; do not rewrite the OTA note.)

Concerns Identified: [safety issues, barriers, equipment needs, indications for escalation, or none identified]

Clinical Direction and Plan

• Guidance to OTA: [intervention progression, safety strategies, precautions, technique modifications]
• Care Team Communication: [contacts made and content] (Include only if relevant.)
• POC/Goals Status: [reviewed, no modifications / changes made] (If changes made, document what changed, rationale, effective date, and where canonical POC was updated.)
• Delegation Scope: [no change / changes to delegation] (If changed, specify tasks and supervision level.)
• Follow-Up: [next supervision action and timeframe]

Attestation

• [I reviewed and concur with OTA documentation as referenced / I reviewed and do not fully concur—see above]
• [Supervision occurred consistent with applicable state practice act, payer requirements, and facility policy]
• [Clinical judgments and POC decisions were made by the Supervising OT]
• [Date of last on-site supervisory visit: date / not applicable] (Include if required by policy.)

(If unable to verify required information, state explicitly with follow-up plan rather than leaving blank.)

Signature

Supervising OT Signature: [signature, credentials, date/time]

(If co-signature on the OTA note serves as supervision documentation, ensure co-signature captures identity, date/time, and role.)