3,138 uses
Occupational Therapy Session Note
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Finished note
Example — generated by Notat from a sample visit
Presenting concern: Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm. Assessment: Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed. Plan: Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise. Clinical documentation: Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.
FactsContext™
symptoms
Anxiety: Increased anxiety during work-related stress
Sleep: Disrupted sleep
denials of symptoms
Denies: Risk: Denies thoughts of self-harm
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
plan
Support: Coping strategies, sleep routine, and follow-up discussed
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
Template
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]
Shared by
SO
Sarah O’Connell
Mental Health Counselor, Ireland
How it works in Notat
Add this template to your library, record the visit as usual, and Notat drafts the note in this exact structure from the extracted clinical facts. You review, edit, and sign.
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