Telehealth OT Visit Note

Date/Time of Service: [Date and time of encounter]

Patient: [Name] | [DOB or MRN per facility policy]

Provider: [Name], [Credentials], [Role: OTR/L or OTA]

Supervising OT: [Name and review date] (Include only for OTA notes requiring cosignature)

Diagnoses/Precautions: [Primary OT-related diagnoses] | [Precautions relevant to today's session]

Visit Number: [Visit count within episode] (Include only if tracked)

Telehealth Attestation

• [Synchronous audio-video / Audio-only] via [Platform name]
• Connection quality: [Stable / Unstable - describe] | [Interruptions and time paused if applicable]
• Identity verification: [Method used]
• Patient location: [City, State] (Include full address when emergency planning is clinically indicated)
• Provider location: [City, State or facility site]
• Participants present: [Name(s), relationship(s)] | Patient permission: [Confirmed / Not confirmed]
• Telehealth consent: [Verbal / Electronic / Written] per policy | Recording consent: [Obtained / Not applicable]
• Privacy: Provider setting [Private / Limitations: describe]; Patient setting [Private / Limitations: describe]
• Safety/emergency readiness: Callback number [Number]; Emergency contact [Name/Number] (Include when clinically indicated); Environment ready for planned tasks: [Yes / No - describe]

(If visit could not proceed due to safety, privacy, or technical issues, document reason, guidance provided, and reschedule plan. Never infer consent, identity verification, location, privacy, or emergency readiness—explicitly document each element.)

Subjective

Patient's stated priorities/focus: "[Direct quote if meaningful]"

Interval changes since last visit: [Changes in function, symptoms, routines, or environment] (Attribute source as patient- or caregiver-reported)

Home program adherence: [What was done, frequency, barriers] | Adverse events: [Falls, equipment issues, or none reported]

(Omit Subjective only if visit was purely administrative or aborted before clinical interaction)

Objective

Telehealth setup limitations: [Camera positioning, lighting, partial views, audio issues, or none]

• Observed via video: [Functional performance in occupations/tasks addressed today] (Use qualifying language: "appears," "consistent with," "observed behavior suggests")
• Patient-reported: [Symptoms, performance, outcomes relevant to today]
• Caregiver-reported/measured: [Observations or measurements with source noted]
• Standardized measures: [Measure name], [Score], [Standard / Modified for telehealth] (Include only if administered)
• Time documentation: Total session time [Minutes]; Skilled treatment time [Minutes] (Include if required for billing)

(Include only items assessed today. Keep data source explicit for each finding.)

Interventions

• [Goal/Problem area]: [Intervention type] | Parameters: [Reps/sets/duration/intensity] | Cueing: [Type and level] | Telehealth method: [Screen share / Verbal coaching / Modeling / Teach-back / Caregiver facilitation]
• Education provided: [Topic] to [Audience] | Understanding demonstrated: [Teach-back / Return demonstration / Verbalization]
• Home program: [Assigned/updated activities] | Frequency: [As prescribed] | Safety guidance: [Key points]

(Repeat goal/problem structure as needed. Use action verbs to reflect skilled clinical reasoning.)

Assessment & Plan

Assessment: [Clinical interpretation of today's performance; key barriers and facilitators; progress toward goals] | Skilled OT required today for: [Justification]. Telehealth appropriateness: [Remains appropriate / Recommend hybrid or in-person - with rationale]. Remote observation limitations: [Specify constraints or none].

Plan: Next session focus: [Areas/activities] | Modality: [Telehealth / In-person / Hybrid]. Frequency/duration changes: [As applicable with rationale]. Coordination: [Referrals, team communication, equipment needs]. Discharge planning: [Criteria, timeline, transition plan] (Include if approaching discharge)

(Do not copy forward prior content without updating for today's session.)