Sensory Integration Intervention Note (Pediatric)

Pediatric Sensory Integration Intervention Note

Date of Service: [Date]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

Provider Name/Credentials: [Name, credentials]

Location: [clinic / school / home / telehealth]

Encounter Type: [individual / group]; [in-person / telehealth]

Supervising OT: [Supervising OT name/credentials] (Include only if OTA is documenting; otherwise omit this line.)

Precautions: [seizure / shunt / vestibular / behavioral safety / orthopedic / None identified]

Present: [Caregiver(s), teacher/aide, interpreter as applicable]

Subjective

[Caregiver or teacher report since last session] (Briefly capture functional updates related to sensory processing: transitions, tolerance for self-care tasks, school participation, sleep, peer play, community outings. Include reported triggers, meltdowns, and effective calming strategies. Note any medical changes such as illness or medication. If no new concerns, write: "No new concerns reported." If caregiver not present, write: "Subjective report not obtained" and note how carryover education was or will be addressed.)

Objective

Baseline State: [Arousal level, affect/engagement, attention, transition into session] (Use observable terms; quantify when possible, e.g., time-to-settle, prompts needed, co-regulation level.)

Intervention Block 1: [Targeted goal from plan of care]

• Activity/Setup: [Activity with sensory-motor parameters: input type, intensity, duration, grading, environmental setup]
• Assist/Cueing: [Level and type of assist/cueing provided]
• Child Response: [Regulation changes, adaptive responses, quantified outcomes]
• Skilled OT Actions: [Grading decisions, positioning, real-time strategy coaching]

Intervention Block 2: [Targeted goal from plan of care]

• Activity/Setup: [Activity with sensory-motor parameters]
• Assist/Cueing: [Level and type of assist/cueing]
• Child Response: [Regulation changes and quantified outcomes]
• Skilled OT Actions: [Grading and strategy coaching details]

(Duplicate intervention blocks as needed for each distinct activity. Include at least one functional participation component linking sensory-motor work to home, school, or play occupations. Note any safety measures or adverse responses with actions taken, if applicable.)

Caregiver Education

• Topic(s): [Regulation strategies / transition supports / sensory diet concepts / home program activities]
• Method: [verbal / demonstration / handout / teach-back]
• Caregiver Response: [Teach-back accuracy, stated understanding, questions]
• Home Program Assigned: [Specific activities with frequency and safety guidance]

(If caregiver not present, document alternative method: handout sent, follow-up call planned. Omit this section entirely if no education provided this session.)

Assessment

[Clinical interpretation of session] (Address progress toward each targeted goal as [improved / unchanged / regressed] with supporting evidence. Summarize observed sensory regulation pattern and impact on participation. Note effective and ineffective strategies with clinical reasoning for grading choices. Identify barriers if relevant. If no progress, document rationale and planned adjustments.)

Plan

• Next Session Focus: [Planned sensory system(s) and functional targets]
• Anticipated Grading: [Progressions or modifications planned]
• Carryover Strategies: [Home/school recommendations]
• Coordination: [Planned communication with teacher/caregiver/other disciplines]
• Frequency/Duration Changes: [Updates with rationale, if any]

Total Treatment Time: [minutes]

Timed-Code Minutes: [minutes] (Include if applicable for billing.)

Provider Signature/Credentials: [Name, credentials]

Date/Time Signed: [MM/DD/YYYY HH:MM]

Co-signature: [Name, credentials] (Include only if required per setting policy.)