Occupational Therapy Session Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Session Activity:
- [specific activities or interventions performed during the session]

Subjective:
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc]

Staff update:
- [describe handover information from staff, recent behaviour, recent updates from staff, presentation of individual since last visit]

Client update:
- [describe current issues raised by patient, any specific updates provided by patient, discussion topics patient stated, any presenting complaints etc]
- [Mention any complaints or requests, symptoms etc]
- [Mention Duration/timing/location/quality/severity/context of complaint]
- [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness]
- [Progression: Mention describe how the symptoms have changed or evolved over time]
- [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes]
- [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities]
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] 

Objective:
- [vital signs]
- [physical examination findings]
- [Mental state examination findings, including system specific examination(s)]
- [Investigations with results]

Assessment:
- [diagnosis or clinical impression]
- [differential diagnosis]
- [Likely diagnosis]

Plan:
- [treatment plan, including medications, therapies, and follow-up appointments]
- [patient education and counselling]
- [referrals to other healthcare providers]
- [Investigations planned] 
- [Treatment planned] 
- [Relevant other actions such as counselling, referrals etc]