Time is the new currency, and better spent with clients than on paperwork. It’s especially true for Occupational Therapy documentation, where reports such as Progress Notes, Assessment Forms, and other reports can quickly take up a huge chunk of your working day.
But the OT profession has gone digital, and forms, notes, and documents can easily be created online using the right tools, such as custom form builders, autofill features, and more. If you’re looking for examples of treatment plans to create, these examples and Occupational Therapy software solutions will help you run your OT practice with a lot more efficiency.
Before you continue, we thought you might like to try out Quenza’s Occupational Therapy features for $1. Our simple-to-use software will help you deliver your own, personalized interventions to help others more effectively, so that you can bring your patients more positive health results for a happier, healthier life.
OT Documentation and Treatment Plans: 5 Examples
Designing corporate branded Occupational Therapy Documentation can be quick and simple in discipline-specific Occupational Therapy apps, which often provide OT documentation templates and custom form creation tools.
Using guidelines such as these OT documentation and treatment plan examples, practitioners can save time by building a template that includes all the key elements, then customizing different sections with rating scales, tickboxes, body charts, and other insurance or practice information.
- The official American Occupational Therapy Association (AOTA) Guidelines specify what OT documents should cover, including a patient’s OT history and needs, the treatment rationale, a chronological record of the client’s OT status, and other vital information. This official overview, published in The American Journal of Occupational Therapy, classifies the different types of screening, evaluation, intervention, and outcome documents that are commonly required by practices, with essential and suggested fields to include in each. A Therapy Progress Note, for instance, should include the client’s information, a services summary, an overview of their current performance, and their treatment plan or recommendations.
- SOAP notes are another very widely used OT documentation, and easily understood by all providers involved in a patient’s treatment plan. SOAP notes use a 4-step framework to summarize Subjective, Objective, Assessment, and Plan information on a client at any stage of their therapy – these templates are typically included in all good Occupational Therapy documentation software. Tools such as drop-down boxes for common symptoms, ICD codes, and subjective pain scales are all useful features that can be embedded into custom SOAP note forms for more clarity. For 3 great examples of SOAP notes, check out our article on Writing SOAP Notes: Step-by-Step Guide, Examples & Templates.
- Nurse Key also provides an example Occupational Therapy Evaluation form from Pendleton and Schultz-Khron’s Pedretti’s Occupational Therapy Practice Skills for Physical Dysfunction. This OT Treatment Plan example document can be used to structure a practitioner’s occupational profile, which contains initial client information for their chart. As Figure 12-2 shows, it covers data on their Activities of Daily Living, Performance Skills, Short Term Goals, and Long Term Goals.
3 Valuable Documentation and Assessment Forms
Occupational Therapists can save time by building templates from key elements, then customizing different sections with rating scales, tickboxes, body charts, and other insurance or practice information.
Various government and medical school websites provide templates for practitioners to use when conducting OT services for the public.
These are brilliant templates for private practitioners to use when creating their own occupational therapy forms for Functional Independence Assessments, Home Services Needs Assessments, and Home Modifications Assessments.
Home Modifications Assessment Forms Example
The Victorian Government’s TAC in Australia, for example, offers OT assessment form examples for all of these, such as the Home Modifications Assessment Form snippet shown below.
Your own indicators can often be swiftly added to custom forms from the system’s library with high-quality OT and Physical Therapy software.
Alternatively, you might create your own list of indicators or symptoms when configuring your practice management system on Day One.
Example OT Assessment Data Set Form
Assessment Forms can also be created on specialized Occupational Therapy software such as Quenza, as shown below.
Here, both form design and subsequent note-taking can be sped up with drop-down menus and multiple-choice fields.
Digital OT forms can also be edited or filled out on mobile devices, by both practitioner or patient depending on the form.
With this Quenza example, it’s clear to see how different question formats make form creation and completion much easier – a combination of tick boxes, multiple-choice options, and free data entry fields can be used for Sensorimotor Component information, Patient Details, and other sections.
With all OT Assessment forms, the ability to PDF, print, sign, lock, and digitally share can help your practice run much more efficiently.
Example Occupational Therapy Assessment Types
The UK’s Royal College of Occupational Therapists (RCOT) has a comprehensive OT manual that comes in very handy for practitioners designing their own forms.
This OT assessment document lists all the assessments you may want to enter into a therapy software system when setting up for quick form creation at a later date.
As well as lists of various Occupational Therapy scales and measures – which you may choose to offer digitally for patients to complete online, it provides an appendix of the terminology used in assessments.
OT Intake Form Template
Therapy intake forms are the first thing patients fill in when registering to your practice, and also the first impression they’ll have of you as a professional provider.
In Therapy Intake Forms: A Patient Wellbeing Essential, you’ll find a full overview of how to create your own intake forms alongside tips, templates, and examples to help you.
Our article on Conducting Effective Intake Sessions is another helpful resource if you’re hoping to design a smooth onboarding process, with questions you can ask, plus a little more on the “Why” and “How” of building positive, engaging client relationships.
Practice Management: 3 Billing and Documentation Software Solutions
Invoices, reports, and notes aren’t the main reason practitioners go into Occupational Therapy – but they can take up a great deal of time when you’re running your own business.
With a few standard templates and tools, a huge amount of professional paperwork can be digitalized and shared online with clients under your own custom brand.
These are some practice management platforms with features that OT specialists will likely find helpful.
|A Saas platform designed for OT professionals, as well as physios and other therapists who provide online care for patients at home.|
The software includes invoicing, calendar management, staff management, and reports functions, plus Occupational Treatment Plan features. One drawback of TherapyBoss is that it supports custom form creation, but provides no specialty-specific forms for Occupational Therapists.
|Price||79¢+ per visit|
|Good For||Occupational Therapy, Physical Therapy, Speech Therapy, Social Work, Telecounseling|
|Fusion Web Clinic includes features developed especially for Pediatric OTs, as opposed to adult OT service providers. With over 80+ “quick phrases” and therapist-designed forms to choose from, the software includes Occupational Therapy templates that can easily be tweaked or customized.|
The app includes SOAP note formats and more. However, a minimum of five users are required for Fusion’s entry-level pricing package.
|Name||Fusion Web Clinic|
|Price||$29+ monthly per user|
|Good For||Occupational Therapy, Physical Therapy, Speech Therapy|
|MyClientsPlus is designed for solo Occupational Therapists and small-to-medium-sized providers. Its form library includes Occupational Therapy Assessment Forms, therapy progress note templates, intake forms, and more.|
MCP also comes with telehealth video-conferencing capabilities for video coaching and a client portal for OT documentation uploads, where Therapy Intake Forms and OT Informed Consent Documents can be shared digitally. While it offers custom form fields and allows users to brand documents, its user experience involves juggling two separate tabs to access the full telehealth features.
|Good For||Occupational Therapy, Physical Therapy, Telepsychology, Telepsychiatry, Speech Therapy, Massage Therapy, Fitness Coaching, Video Coaching, Wellness Coaching.|
|More info||My Clients Plus|
|Quenza is a web- and mobile-based OT software solution for creating documents, reports, notes, and assessment forms faster. Its Expansion Library contains a wealth of templates that can quickly and simply be customized to create professional Occupational Therapy documentation.|
Developed for online therapists, coaches, and other blended care practitioners, this tool instead provides multiple-choice questions, free-form, and short-answer fields in its Activity Builder to speed up the documentation process of creating therapy notes and more. Using the same straightforward tools, OTs can also design personalized interventions using video, audio, images, and other multimedia.
|Good For||Occupational Therapy, Physical Therapy, Speech Therapy, Blended Therapy|
Our 3 Favorite OT Apps
With smartphone ownership set to reach 73% in 2021, apps are the go-to for Occupational Therapists hoping to manage their practice online. These Occupational Therapy apps include tools for your mobile, as well as web-based apps for in the office.
|For very basic custom form creation, GoCanvas is one mobile option with free packages for solo Occupational Therapy providers. Using this standalone tool, users can create custom forms with smart fields for PDF export.|
This app will allow providers to collect intake information by designing Occupational Therapy forms, as well as relevant patient data between sessions. Still, while it comes at an affordable price, it doesn’t offer any of the specialty-specific tools of more robust Occupational Therapy apps.
|Good For||Occupational Therapy, Physical Therapy, Speech Therapy, Data Collection|
|TheraPlatform is a HIPAA-compliant video therapy and practice management solution for therapists, with a few form-building features for OTs, physical therapists, and mental health professionals.|
Create Intake Forms using templates, then customize your fields accordingly to create notes for treatment plans, Occupational Therapy assessment forms, and more. This platform is also an EMR with a Client Portal, and prices start at $29 per month, per single provider.
|Good For||Occupational Therapy, Physical Therapy, Speech Therapy, e-Mental Health, Telehealth|
|Clinicient is a bespoke tool for OT documentation with a customizable library of templates, content, and reports. Professionals can also use this OT app to create treatment plans, customize measurement protocols, and produce client surveys and correspondence.|
With your tablet, smartphone, or laptop, you can create initial evaluation documents, progress notes, therapy notes, discharge forms, and e-sign your digital paperwork.
|Price||Available on request|
|Good For||Occupational Therapy, Physical Therapy, Speech Therapy|
Intake forms, initial assessments, and treatment plans are all essential to amazing patient care. But when OT documentation takes more time than you spend with clients, reliable Occupational Therapy software can be just as important.
Whether you’re looking to design your own forms or tweak a template, today’s market is full of specialty-specific and more general tools at all kinds of price points. Hopefully, this guide will help you find the right one for you as a provider, so you can start sharing your own forms for a more efficiently-run practice.
We hope you enjoyed exploring the world of OT apps with us. Don’t forget to sign up for our $1 trial to test out all of Quenza’s occupational therapy tools and features.
If you’d like to help more clients achieve better health, Quenza is an all-in-one OT software that contains everything you need to streamline your documentation, help others with custom interventions, and maximize the positive impact of your occupational therapy solutions.
- ^ Clark, G. F., & Youngstrom, M. J. (2013). Guidelines for documentation of Occupational Therapy. The American Journal of Occupational Therapy, 67(6), S32.
- ^ Adler, C., & Schultz-Khron, W. (2006). Pedretti's Occupational Therapy Practice Skills for Physical Dysfunction. Elsevier: St Louis.
- ^ Statista. (2021). Smartphone penetration rate as share of the population in the United States from 2010 to 2021. Retrieved from https://www.statista.com/statistics/201183/forecast-of-smartphone-penetration-in-the-us/