School-Based OT Service Note (IEP/504)

Student Name: [Student full name]

Student ID: [Student ID]

School / Grade / Teacher: [School] / [Grade] / [Teacher name]

Date of Service: [MM/DD/YYYY]

Start Time: [Start time] End Time: [End time]

Total Minutes: [Total minutes]

Service Type: [direct individual / direct group / push-in / pull-out / consultation / missed session] (If direct group, include group size: [Group size])

Plan Type: [IEP / 504]

Location/Setting: [Location or setting]

Provider Name and Credentials: [Provider name, credentials]

Session Status

[Session provided as scheduled / modified / not provided]. [Reason if modified or missed]. [Make-up plan if applicable]. (Use objective, nonjudgmental language. Limit to 1–2 sentences. If session was not provided, complete only this section and omit remaining sections.)

Presenting Context

[Brief contextual factors that materially affected today's intervention, participation, or data interpretation] (Include only if relevant factors were present; otherwise omit this section entirely. May include brief student or staff report, observable engagement factors, or safety-relevant observations. Use direct quotes sparingly and pair with clinical description.)

Goal Addressed and Objective Data

(For each IEP goal or 504 support addressed today, complete a separate block. Repeat as needed for multiple goals.)

Goal/Support: [IEP goal number and title OR 504 functional access area]

Task/Context: [Activity, materials, setting conditions, and supports in place]

Skilled OT Intervention: [Skilled actions requiring OT expertise: task grading, cueing strategies taught or used, environmental modifications, motor or sensory strategy instruction, staff coaching within routine] (Describe clinical reasoning and skilled actions, not merely activities performed.)

Data: [Objective performance measures mapped to goal criteria: trials and accuracy, prompting/cueing level, duration, quality indicators, and conditions under which data were collected]

Student Response

[Brief clinical interpretation of today's findings in relation to goal progress and educational participation] (2–4 sentences. Indicate whether performance suggests [improving / stable / regressing] relative to criteria, factors that helped or hindered performance, and evidence of generalization or carryover. Reference today's data specifically. Do not diagnose or infer medical causation.)

Plan

• [Next session focus linked to goal or support area]
• [Planned modifications based on today's response: grade task up or down, adjust tools, alter environment, increase or fade supports]
• [Carryover recommendations for classroom staff] (Include only if provided; note what was communicated and expected action.)
• [Collaboration: who by role, what was communicated or trained, resulting action] (Include only if collaboration occurred this session.)
• [Plan to adapt approach or convene team discussion if progress limited; if service model or frequency changes needed, document rationale and plan to address via IEP or 504 process] (Include only if applicable.)