Write an occupational therapy initial evaluation report.

Patient: [AGE, SEX, DIAGNOSIS — e.g., 67-year-old female, right CVA with left hemiplegia]
Referral source: [PHYSICIAN NAME AND REASON FOR REFERRAL]
Setting: [OUTPATIENT / SNF / HOME HEALTH / SCHOOL-BASED / ACUTE CARE]
Chief occupational concern: [PATIENT'S PRIMARY FUNCTIONAL LIMITATION IN THEIR OWN WORDS]
Occupational profile: [PRIOR LEVEL OF FUNCTION — what the patient was able to do independently before onset; living situation; roles and routines]
Standardized assessments administered: [ASSESSMENT NAMES AND SCORES — e.g., FIM motor subscale: 42/91; Jebsen-Taylor Hand Function Test; MMSE: 22/30]
ADL status: [CURRENT PERFORMANCE — bathing, dressing, grooming, toileting, feeding — independence level for each]
IADL status: [CURRENT PERFORMANCE — meal prep, home management, community mobility, medication management]
Upper extremity function: [ROM, STRENGTH, COORDINATION, SENSATION — affected limb(s)]
Cognitive and perceptual status: [ATTENTION, MEMORY, PROBLEM SOLVING, VISUAL PERCEPTION IF RELEVANT]
Short-term goals (2–4 weeks): [MEASURABLE, FUNCTIONAL — tied to specific ADL tasks]
Long-term goals (6–8 weeks): [DISCHARGE-LEVEL FUNCTIONAL OUTCOMES]
Frequency and duration: [RECOMMENDED TREATMENT PLAN — e.g., 3x/week x 8 weeks]

Professional OT evaluation format. Connect impairments directly to occupational performance deficits. Under 600 words.

Write a SOAP note for an occupational therapy ADL training session.

Patient: [AGE, DIAGNOSIS]
Session focus: [SPECIFIC ADL — e.g., upper body dressing / shower transfer / meal preparation]
Subjective: [PATIENT'S REPORT — pain, fatigue, motivation, any changes since last session]
Objective: [WHAT WAS OBSERVED AND MEASURED — functional performance level, assist level required (min A / mod A / max A / dep), compensatory strategies used, adaptive equipment trialed]
Assessment: [PROGRESS TOWARD GOAL — improving / plateaued / declining + clinical reasoning for status]
Plan: [NEXT SESSION FOCUS, MODIFICATIONS TO TREATMENT APPROACH, HOME PROGRAM UPDATES]
Skilled justification: [ONE SENTENCE — why OT skilled services are required for this patient at this time]

Under 300 words. Skilled justification is required for Medicare compliance — do not omit.

Write a SOAP note for an occupational therapy upper extremity rehabilitation session.

Patient: [AGE, DIAGNOSIS — e.g., 54-year-old male, s/p right distal radius ORIF, 6 weeks post-op]
Session focus: [UE SKILL — e.g., active ROM exercises, scar mobilization, strengthening, functional task practice]
Subjective: [PAIN RATING 0–10, FUNCTIONAL COMPLAINTS, COMPLIANCE WITH HOME PROGRAM]
Objective: [MEASUREMENTS — AROM/PROM with goniometric values by joint and plane of motion; grip strength in lbs/kg; pinch strength; edema measurements if applicable; coordination testing results]
Assessment: [PROGRESS TOWARD FUNCTIONAL UE GOALS — compare to prior measurements; explain clinical significance of changes]
Plan: [NEXT TREATMENT FOCUS, HOME EXERCISE PROGRAM PROGRESSION, ANTICIPATED TIMELINE]
Skilled justification: [WHY SKILLED OT IS REQUIRED — e.g., complexity of scar management, need for manual techniques, adaptation of HEP]

Under 350 words. Include specific numeric measurements — documented progress justifies continued skilled care.

Write a SOAP note for an occupational therapy cognitive rehabilitation session.

Patient: [AGE, DIAGNOSIS — e.g., 72-year-old male, TBI with attention and memory deficits]
Cognitive targets: [DOMAINS ADDRESSED — attention, memory, executive function, problem solving, visual perceptual skills]
Subjective: [PATIENT AND/OR CAREGIVER REPORT — functional concerns, changes at home]
Objective: [SPECIFIC TASKS PERFORMED AND PERFORMANCE — e.g., sustained attention during 10-minute cooking task: 3 verbal cues required, decreased from 6 last session; memory log completed with 2 setup cues; Allen Cognitive Level if applicable]
Assessment: [PROGRESS IN COGNITIVE DOMAINS AND FUNCTIONAL IMPLICATIONS — how cognitive changes affect ADL performance]
Plan: [GRADING PLAN — task complexity progression, compensatory strategy training, caregiver education topics]
Skilled justification: [CLINICAL COMPLEXITY REQUIRING SKILLED OT — e.g., grading of cognitive demands, monitoring for safety, caregiver training in compensatory techniques]

Under 350 words.

Write an occupational therapy re-evaluation note.

Patient: [AGE, DIAGNOSIS]
Time since initial evaluation: [WEEKS]
Reason for re-evaluation: [PROGRESS REVIEW / SIGNIFICANT CHANGE IN STATUS / PRIOR AUTH RENEWAL / 30-DAY MEDICARE REQUIREMENT]
Reassessment findings: [STANDARDIZED SCORES COMPARED TO INITIAL — include specific values and deltas; e.g., FIM motor: 42 → 58; grip strength: 12 lbs → 24 lbs right]
Goal status: [FOR EACH GOAL — met / in progress / not met + explanation]
Remaining deficits: [SPECIFIC FUNCTIONAL LIMITATIONS STILL PRESENT]
Revised goals: [UPDATED SHORT-TERM AND LONG-TERM GOALS — specific, measurable, functional]
Updated treatment plan: [FREQUENCY, DURATION, AND FOCUS FOR NEXT TREATMENT PERIOD]
Prognosis: [GOOD / FAIR / GUARDED + RATIONALE — factors affecting recovery]

Under 500 words. Re-evaluations justify continued skilled care — be specific about measurable progress and remaining functional deficits.

Write an occupational therapy functional independence measure (FIM) documentation note.

Patient: [AGE, DIAGNOSIS]
Assessment context: [INITIAL / INTERIM / DISCHARGE]
FIM scoring key: 7=Complete Independence, 6=Modified Independence, 5=Supervision, 4=Minimal Assist, 3=Moderate Assist, 2=Maximal Assist, 1=Total Assistance

Self-care scores:
- Eating: [SCORE + BRIEF DESCRIPTION OF PERFORMANCE]
- Grooming: [SCORE + BRIEF DESCRIPTION]
- Bathing: [SCORE + BRIEF DESCRIPTION]
- Dressing – Upper body: [SCORE + BRIEF DESCRIPTION]
- Dressing – Lower body: [SCORE + BRIEF DESCRIPTION]
- Toileting: [SCORE + BRIEF DESCRIPTION]

Motor FIM subtotal: [SCORE]
Cognitive FIM scores (if OT completing): [SCORES FOR COMPREHENSION, EXPRESSION, SOCIAL INTERACTION, PROBLEM SOLVING, MEMORY]
Total FIM score: [SCORE / 126]

Narrative: [CLINICAL INTERPRETATION — what these scores mean for the patient's level of independence and care needs]

Standard FIM documentation format. Under 300 words.

Write an occupational therapy IADL assessment documentation note.

Patient: [AGE, DIAGNOSIS, LIVING SITUATION — lives alone / with spouse / assisted living]
Assessment tool used: [LAWTON IADL SCALE / OT-specific observation / other]
IADL performance observations:

- Meal preparation: [INDEPENDENCE LEVEL AND KEY OBSERVATIONS — safety, sequencing, endurance]
- Home management (cleaning, laundry): [INDEPENDENCE LEVEL AND OBSERVATIONS]
- Medication management: [INDEPENDENCE LEVEL — ability to open containers, identify medications, adhere to schedule]
- Financial management: [INDEPENDENCE LEVEL — ability to manage bills, make transactions if applicable]
- Telephone/communication device use: [INDEPENDENCE LEVEL]
- Transportation/community mobility: [INDEPENDENCE LEVEL — driving status, use of public transit]
- Shopping: [INDEPENDENCE LEVEL AND OBSERVATIONS]

Summary: [FUNCTIONAL INTERPRETATION — which IADLs are at risk, what supports are needed for safe community/home living]
Recommendations: [SPECIFIC OT INTERVENTIONS, ADAPTIVE EQUIPMENT, HOME MODIFICATION REFERRALS, CAREGIVER TRAINING NEEDS]

Under 350 words.

Write an occupational therapy home safety assessment documentation note.

Patient: [AGE, DIAGNOSIS, MOBILITY STATUS — ambulatory with/without device, wheelchair user, etc.]
Assessment performed: [IN PERSON / TELEHEALTH / CAREGIVER REPORT]
Home environment: [HOUSE / APARTMENT / FLOOR — number of floors, elevator access, entry steps]

Safety findings by area:
- Bathroom: [FINDINGS — grab bar presence/absence, tub/shower configuration, toilet height, fall hazards]
- Bedroom: [FINDINGS — bed height, pathway, lighting, access to call device]
- Kitchen: [FINDINGS — item accessibility, stovetop safety, seating availability]
- Living areas: [FINDINGS — rug hazards, furniture for support, pathway clearance]
- Entryway/stairs: [FINDINGS — handrail presence, step height, lighting]

Fall risk factors identified: [INTRINSIC — balance, strength, medication effects / EXTRINSIC — environmental hazards]
Recommendations: [SPECIFIC — list each modification with priority level: urgent / recommended / optional]
Equipment ordered or recommended: [DURABLE MEDICAL EQUIPMENT — specific items]
Caregiver education provided: [TOPICS COVERED]

Under 400 words.

Write an occupational therapy seating and wheelchair positioning assessment note.

Patient: [AGE, DIAGNOSIS, WEIGHT, HEIGHT]
Current seating: [EXISTING CHAIR/WHEELCHAIR — type, age, condition]
Reason for assessment: [NEW EQUIPMENT REQUEST / EXISTING EQUIPMENT MODIFICATION / PRESSURE INJURY PREVENTION / FUNCTIONAL POSITIONING]
Postural assessment findings: [PELVIS, TRUNK, HEAD/NECK, UPPER EXTREMITIES — alignment, deformities, asymmetries]
Skin integrity: [CURRENT PRESSURE INJURY STATUS — Braden Scale score if applicable]
Functional goals requiring positioning support: [WHAT THE PATIENT NEEDS TO DO FROM THEIR SEATING — propulsion, ADL performance, communication, work tasks]
Equipment recommended: [SPECIFIC — wheelchair type, cushion type, back support, positioning components — with clinical justification for each]
HCPCS codes: [CODES FOR RECOMMENDED EQUIPMENT]
Medical necessity justification: [CONNECT POSTURAL FINDINGS TO FUNCTIONAL NEED — required for DME authorization]

Under 400 words. Medical necessity language must be specific — generic justifications are denied.

Write an occupational therapy splint or orthosis fabrication and fitting note.

Patient: [AGE, DIAGNOSIS]
Orthosis type: [SPECIFIC NAME — e.g., volar resting hand splint, thumb spica, dynamic extension splint]
Indication: [CLINICAL REASON — diagnosis, deformity being addressed, functional goal]
Materials used: [THERMOPLASTIC MATERIAL, PADDING, STRAPS]
Fabrication: [POSITION OF SPLINT — degrees of joint angles for each relevant joint]
Wearing schedule: [HOURS PER DAY — day/night schedule, activity-based instructions]
Patient education provided: [DONNING/DOFFING INSTRUCTIONS, SKIN CHECK EDUCATION, CLEANING INSTRUCTIONS]
Fit assessment: [PRESSURE AREAS CHECKED, ADJUSTMENTS MADE AT FITTING]
Patient tolerance: [INITIAL RESPONSE TO WEAR]
Follow-up: [WHEN SPLINT WILL BE REASSESSED]

Under 300 words.

Write a Medicare functional reporting note for occupational therapy services.

Patient: [NAME, AGE, MEDICARE BENEFICIARY]
Reporting period: [EVALUATION / 10TH VISIT / DISCHARGE]
Primary functional limitation category: [SELECT — Self-Care (GG0130) / Mobility (GG0170) / Other Therapy — see below]

G-Code pair for primary limitation:
- Current status G-code: [G-CODE — e.g., G8978 for self-care complete/activity limitation]
- Modifier: [CH=0% / CI=1–19% / CJ=20–39% / CK=40–59% / CL=60–79% / CM=80–99% / CN=100% impairment]

G-Code pair for discharge goal:
- Goal status G-code: [G-CODE]
- Modifier: [EXPECTED LEVEL AT DISCHARGE]

Functional limitation description: [PLAIN LANGUAGE DESCRIPTION OF THE LIMITATION — what the patient cannot do or does with difficulty, tied to the G-code category]
Standardized assessment supporting G-code selection: [ASSESSMENT NAME AND SCORE]
Therapy necessity statement: [WHY SKILLED OT IS REQUIRED TO ADDRESS THIS FUNCTIONAL LIMITATION]

Under 250 words. G-code selection must be supported by objective assessment data — do not select modifiers without documentation.

Write a Medicare GG0130 self-care functional reporting documentation note.

Patient: [AGE, DIAGNOSIS]
GG0130 subcategories assessed:
- GG0130A — Eating: [ADMISSION SCORE / GOAL SCORE — 01=Dependent, 02=Substantial/maximal assist, 03=Partial/moderate assist, 04=Supervision, 05=Setup, 06=Independent, 07=Patient refused, 09=Not applicable, 10=Not attempted due to environmental limitations, 88=Not attempted due to medical condition]
- GG0130B — Oral hygiene: [ADMISSION / GOAL]
- GG0130C — Toileting hygiene: [ADMISSION / GOAL]
- GG0130E1 — Shower/bathe self: [ADMISSION / GOAL]
- GG0130F1 — Upper body dressing: [ADMISSION / GOAL]
- GG0130G1 — Lower body dressing: [ADMISSION / GOAL]
- GG0130H1 — Putting on/taking off footwear: [ADMISSION / GOAL]

Clinical narrative: [CONNECT SCORES TO SPECIFIC FUNCTIONAL OBSERVATIONS — what the patient does and does not do during each self-care task, with assist level and cueing requirements]
OT skilled care justification: [WHY SKILLED OT IS REQUIRED FOR THIS SELF-CARE FUNCTIONAL LIMITATION]

Under 350 words.

Write an occupational therapy Medicare discharge functional reporting note.

Patient: [AGE, DIAGNOSIS]
Admission date: [DATE] — Discharge date: [DATE]
Total OT visits: [NUMBER]
Primary G-code category: [CATEGORY]

Admission G-code status: [CODE + MODIFIER]
Discharge G-code status: [CODE + MODIFIER — should reflect progress from admission]
Discharge goal G-code: [ORIGINAL GOAL CODE + MODIFIER]

Goal achievement summary:
- Goal 1: [ORIGINAL GOAL] — Status: [MET / NOT MET / MODIFIED — explain]
- Goal 2: [ORIGINAL GOAL] — Status: [MET / NOT MET / MODIFIED — explain]
- Goal 3: [ORIGINAL GOAL] — Status: [MET / NOT MET / MODIFIED — explain]

Functional outcome: [DISCHARGE FUNCTIONAL STATUS — FIM or GG scores at discharge vs. admission]
Reason for discharge: [GOALS MET / PLATEAUED / PATIENT REQUEST / PAYER LIMIT REACHED / TRANSITION TO ANOTHER LEVEL OF CARE]
Discharge recommendations: [HOME PROGRAM, DME, REFERRALS, COMMUNITY RESOURCES]

Under 400 words. Discharge notes must document the clinical rationale for ending skilled services — not just that goals were met.

Write a skilled care medical necessity justification for occupational therapy services.

Patient: [AGE, DIAGNOSIS, COMPLICATING FACTORS]
Payer: [MEDICARE / MEDICAID / COMMERCIAL INSURER — PLAN NAME]
Services requiring justification: [SPECIFIC OT TREATMENTS — e.g., ADL retraining, UE rehabilitation, cognitive rehabilitation, home modification assessment]
Why skilled OT is required (not unskilled or caregiver-provided care): [SPECIFIC CLINICAL REASONING — complexity of condition, required clinical judgment, safety factors, patient-specific response to treatment]
Evidence of progress: [MEASURABLE CHANGES — specific values with dates]
Why continued skilled care is required: [REMAINING DEFICITS AND FUNCTIONAL GOALS — connect to specific functional limitations]
Anticipated discharge timeline and goals: [SPECIFIC TIMELINE AND EXPECTED FUNCTIONAL OUTCOME]

Under 300 words. Medicare contractors look for specificity — generic "patient needs OT" language is insufficient for continued authorization.

Write a documentation note for an OT functional screening completed as part of a Medicare Annual Wellness Visit.

Patient: [AGE, LIVING SITUATION]
Screening tools administered: [E.G., KATZ ADL INDEX, TIMED UP AND GO, MoCA BRIEF SCREEN, IADL QUESTIONNAIRE]
Scores: [RESULTS FOR EACH TOOL WITH NORMATIVE REFERENCE — e.g., TUG: 14 seconds (≥12 sec = elevated fall risk)]
ADL screening findings: [SUMMARY — which ADLs are intact, which show emerging deficits]
Fall risk factors identified: [INTRINSIC AND EXTRINSIC]
Recommendations: [OT EVALUATION INDICATED YES/NO + SPECIFIC RATIONALE / HOME MODIFICATION RECOMMENDATIONS / REFERRALS]
Patient education provided: [TOPICS — fall prevention, energy conservation, assistive device recommendation]
Physician notification: [FINDINGS COMMUNICATED TO ORDERING PHYSICIAN]

Under 300 words.

Write an occupational therapy upper extremity home exercise program.

Patient: [AGE, DIAGNOSIS — e.g., 61-year-old female, s/p left CVA with right UE weakness, AROM limited in right shoulder and hand]
Session-specific context: [CURRENT FUNCTIONAL LEVEL AND WHAT WAS WORKED ON IN CLINIC THIS WEEK]
Functional goal this HEP supports: [E.G., "independently brush hair using right hand within 4 weeks"]
Exercises (include 3–5):
- Exercise 1: [NAME — sets, reps, position, key technique cues in plain language]
- Exercise 2: [NAME — sets, reps, position, key technique cues]
- Exercise 3: [NAME — sets, reps, position, key technique cues]
- Exercise 4 (if applicable): [NAME — sets, reps]
- Exercise 5 (if applicable): [NAME — sets, reps]
Frequency: [HOW MANY TIMES PER DAY / DAYS PER WEEK]
Pain guideline: [E.G., "Stop if pain exceeds 4/10 or you feel sharp pain — this is different from normal muscle fatigue"]
Adaptive equipment to use at home: [IF APPLICABLE]
When to contact us: [SPECIFIC — e.g., "increased swelling, new pain, or difficulty completing the exercises"]

Plain language only. Assume the patient is reading this without a caregiver present. Under 300 words.

Write an occupational therapy ADL home program for a patient with a neurological diagnosis.

Patient: [AGE, DIAGNOSIS — e.g., 58-year-old male, 4 weeks post right CVA with left neglect and mild left hemiplegia]
Target ADL: [SPECIFIC — e.g., morning dressing routine]
Current level: [HOW PATIENT IS CURRENTLY PERFORMING THIS TASK — what they can do, what requires assist]
Compensatory strategies to practice: [SPECIFIC TECHNIQUES — e.g., dress affected side first, weight-bearing through affected arm during dressing, visual scanning cues for neglect]
Step-by-step task routine: [NUMBERED STEPS — practical, specific, in the order the patient should follow]
Caregiver role: [EXACTLY WHAT THE CAREGIVER SHOULD AND SHOULD NOT DO — verbal cue only / physical assist only for X step / stand by for safety]
Safety reminders: [SPECIFIC TO THIS PATIENT'S DEFICITS — e.g., "Always check that your left arm is not caught under your body before standing"]
Goal: [WHAT INDEPENDENCE LEVEL YOU ARE WORKING TOWARD AND WHY IT MATTERS TO THIS PATIENT]

Under 350 words. Caregiver instructions are as important as patient instructions for neurological diagnoses.

Write an occupational therapy energy conservation home program.

Patient: [AGE, DIAGNOSIS — e.g., 49-year-old female with multiple sclerosis, moderate fatigue limiting morning ADL completion]
Energy conservation principles to cover: [SELECT RELEVANT — pacing, work simplification, activity prioritization, rest break scheduling, environmental modifications]
Morning routine modifications: [SPECIFIC RECOMMENDATIONS — e.g., sit to shower, lay out clothes the night before, complete grooming seated at vanity]
Kitchen/meal prep modifications: [SPECIFIC RECOMMENDATIONS — e.g., use slow cooker, prepare meals in batches, store frequently used items at counter height]
Activity prioritization exercise: [BRIEF TOOL — e.g., "Rate your daily tasks as Must Do / Should Do / Nice to Do and protect energy for Must Do tasks first"]
Rest schedule: [SPECIFIC — e.g., "Take a 10–15 minute seated rest break after every 30 minutes of moderate activity"]
Adaptive equipment recommended: [LIST WITH SPECIFIC PURPOSE FOR EACH ITEM]

Under 350 words. Energy conservation is most effective when tied to the patient's specific daily routine — customize to their actual schedule.

Write a home modification recommendation letter from an occupational therapist to a patient and family.

Patient: [AGE, DIAGNOSIS, FUNCTIONAL STATUS]
Assessment performed: [IN HOME / TELEHEALTH / SIMULATED ASSESSMENT DATE]
Priority modifications recommended:

Priority 1 — Urgent (address immediately):
- [MODIFICATION — e.g., install grab bars in shower and next to toilet: specific dimensions and placement]
- [MODIFICATION]

Priority 2 — Recommended within 30 days:
- [MODIFICATION — e.g., remove threshold between bedroom and bathroom]
- [MODIFICATION]

Priority 3 — Optional/long-term:
- [MODIFICATION]

Funding/resource options: [LOCAL AGING SERVICES / MEDICAID WAIVER / VA BENEFIT / NONPROFIT PROGRAMS IF APPLICABLE]
Contractor referral: [CERTIFIED AGING-IN-PLACE SPECIALIST (CAPS) REFERRAL IF AVAILABLE]
What to do first: [PRIORITIZED NEXT STEP — specific action]
Contact us with questions: [PHONE AND HOURS]

Under 400 words. Plain language. Families implement modifications more reliably when they have a clear prioritized list, not a clinical report.

Write an occupational therapy sensory home program for a pediatric patient.

Patient: [AGE, DIAGNOSIS — e.g., 7-year-old with sensory processing disorder, tactile defensiveness and proprioceptive seeking behaviors]
Sensory profile: [BRIEF SUMMARY — which sensory systems are over-responsive, under-responsive, or seeking]
Sensory diet activities (include 4–6):
- Activity 1: [NAME AND PURPOSE — when to use, how long, specific instructions for parent]
- Activity 2: [NAME AND PURPOSE]
- Activity 3: [NAME AND PURPOSE]
- Activity 4: [NAME AND PURPOSE]
- Activity 5 (if applicable): [NAME AND PURPOSE]
- Activity 6 (if applicable): [NAME AND PURPOSE]
When to use this program: [SCHEDULE ANCHORS — e.g., before school, after school, before homework, before bedtime]
Signs it is working: [OBSERVABLE POSITIVE BEHAVIORS — e.g., "able to sit for 10+ minutes, less distress during dressing"]
Signs to contact OT: [E.G., increased agitation, new behaviors, self-injurious responses]
Parent reminders: [KEY NOTES — e.g., "This is not a reward/punishment system — all children receive the sensory diet activities regardless of behavior"]

Under 350 words. Parent implementation success depends on clear, jargon-free instructions.

Write an occupational therapy progress note in skilled justification format.

Patient: [AGE, DIAGNOSIS]
Visit number: [NUMBER] — Date: [DATE]
Treatment provided this session: [SPECIFIC INTERVENTIONS — techniques, modalities, tasks practiced]
Objective measures this session: [SPECIFIC VALUES — FIM scores, ROM, grip strength, task performance time, assist level, cues required]
Comparison to prior session: [SPECIFIC CHANGES — values from last session and this session side by side]
Response to treatment: [HOW PATIENT RESPONDED — tolerance, engagement, fatigue, learning]
Skilled care provided (what required OT clinical judgment): [SPECIFIC — e.g., "graded task complexity based on patient's cognitive response," "modified splint for pressure relief," "trained caregiver in safe transfer technique with two-person assist to single-person"]
Progress toward goals: [GOAL 1 STATUS / GOAL 2 STATUS]
Plan: [NEXT SESSION FOCUS AND ANY PLAN MODIFICATIONS]

Under 300 words. The "skilled care" field is the most important field for Medicare audit survival — never leave it generic.

Write a school-based occupational therapy progress note toward IEP goals.

Student: [AGE, GRADE, DIAGNOSIS]
IEP goal being addressed: [EXACT GOAL LANGUAGE FROM IEP]
Baseline at start of IEP period: [WHAT STUDENT COULD DO AT IEP INITIATION]
Service provided this session: [SPECIFIC ACTIVITIES AND INTERVENTIONS]
Student performance this session: [SPECIFIC OBSERVATIONS — accuracy, assist level, trials completed, strategies used]
Progress toward IEP goal: [MEASURABLE — e.g., "Student completed 8/10 correct letter formations with verbal cue only, compared to 4/10 at baseline"]
Classroom/teacher collaboration: [ANY COMMUNICATION WITH TEACHER, CLASSROOM STRATEGY RECOMMENDATIONS]
Next session focus: [SPECIFIC PLAN]

Under 250 words. IEP progress notes must use measurable language — "improving" is not sufficient for compliance or IEP review.

Write a skilled nursing facility occupational therapy daily skilled care note.

Patient: [AGE, DIAGNOSIS, ADMISSION REASON]
Disciplines treating today: [OT / PT / SPEECH — note OT-specific session]
Session length: [MINUTES]
Treatment focus: [SPECIFIC — self-care, UE strengthening, cognitive training, transfer training, etc.]
Skilled interventions provided: [SPECIFIC TECHNIQUES — not just activity names]
Patient response: [FUNCTIONAL PERFORMANCE OBSERVATIONS, ASSISTANCE LEVEL, FATIGUE, PAIN]
Skilled care justification: [WHAT REQUIRED OT CLINICAL JUDGMENT TODAY — e.g., "Modified ADL approach due to sudden increase in left shoulder pain; assessed for rotator cuff irritation and adjusted HEP"]
Goal progress: [SPECIFIC GOAL STATUS]
Communication with care team: [NURSING NOTIFICATION / PHYSICIAN COMMUNICATION / FAMILY CONTACT]
Plan: [NEXT SESSION FOCUS]
RUG/PDPM documentation note: [FLAG IF SESSION AFFECTS PDPM CLASSIFICATION — e.g., "Patient meets PDPM ADL criteria at CMS code [X]"]

Under 300 words.

Write an occupational therapy outpatient discharge summary.

Patient: [AGE, DIAGNOSIS]
Episode of care: [START DATE] to [END DATE] — Total visits: [NUMBER]
Reason for discharge: [GOALS MET / FUNCTIONAL PLATEAU REACHED / PATIENT REQUEST / INSURANCE LIMIT]

Admission status: [FUNCTIONAL LEVEL AT EVALUATION — FIM scores, key assessment results, primary deficits]
Discharge status: [FUNCTIONAL LEVEL AT DISCHARGE — same measures for comparison]

Goal outcomes:
- Goal 1: [ORIGINAL GOAL] — [MET / PARTIALLY MET / NOT MET] — [CURRENT STATUS]
- Goal 2: [ORIGINAL GOAL] — [MET / PARTIALLY MET / NOT MET] — [CURRENT STATUS]
- Goal 3: [ORIGINAL GOAL] — [MET / PARTIALLY MET / NOT MET] — [CURRENT STATUS]

Discharge instructions: [HOME PROGRAM, ADAPTIVE EQUIPMENT IN USE, CAREGIVER TRAINING COMPLETED]
Referrals made: [ANY REFERRALS AT DISCHARGE — community OT, support groups, physician follow-up]
Return to OT criteria: [SPECIFIC CONDITIONS UNDER WHICH PATIENT SHOULD RETURN — e.g., functional regression, new diagnosis, fall]
Copy to: [REFERRING PHYSICIAN / CARE TEAM]

Under 450 words.

Write a functional status update letter from an occupational therapist to a referring physician.

OT author: [NAME, OTR/L OR COTA/L]
Physician: [NAME, SPECIALTY]
Patient: [NAME, AGE, DIAGNOSIS]
Date of letter: [DATE]
Summary of OT services provided: [DATES OF SERVICE, NUMBER OF VISITS, TREATMENT FOCUS]
Current functional status: [SPECIFIC — ADL independence levels, UE function, cognitive status — use measurable terms]
Progress since referral: [SPECIFIC CHANGES WITH MEASUREMENTS]
Remaining functional deficits: [WHAT THE PATIENT STILL CANNOT DO INDEPENDENTLY]
OT recommendations: [CONTINUED SERVICES / DISCHARGE / REFERRAL TO ANOTHER SERVICE / HOME MODIFICATION]
Clinical question for physician: [IF APPLICABLE — e.g., "Please clarify weight-bearing precautions for left hip to progress transfer training"]
Contact: [DIRECT LINE AND FAX]

Under 300 words. Physician communication letters have clinical and medicolegal standing — be precise.

Write a prior authorization letter requesting continued occupational therapy services.

OT: [NAME, OTR/L, NPI]
Patient: [NAME, AGE, INSURER AND PLAN — MEMBER ID]
Current diagnosis: [ICD-10 CODES]
Services requested: [CPT CODES — e.g., 97165 / 97166 / 97167 / 97530 / 97535 / 97542]
Units requested: [NUMBER OF VISITS AND FREQUENCY — e.g., 12 visits, 2x/week x 6 weeks]
Medical necessity: [SPECIFIC CLINICAL DATA — functional deficit measurements, standardized assessment scores, what patient cannot do independently]
Progress to date: [MEASURABLE IMPROVEMENT ACHIEVED WITH PRIOR AUTHORIZATION — specific values]
Remaining deficits requiring skilled care: [WHAT HAS NOT YET BEEN ACHIEVED AND WHY CONTINUED SKILLED OT IS REQUIRED]
Discharge criteria: [SPECIFIC FUNCTIONAL OUTCOME THAT WILL INDICATE READINESS FOR DISCHARGE]
Without continued OT: [WHAT WILL HAPPEN IF AUTHORIZATION IS DENIED — functional regression risk, safety risk, increased care needs]

Under 350 words. Authorization approvals follow the evidence — every claim must be supported by specific functional data.

Write a prior authorization letter for adaptive equipment or durable medical equipment ordered by an OT.

OT ordering: [NAME, OTR/L, NPI]
Patient: [NAME, AGE, INSURER]
Equipment requested: [SPECIFIC ITEM — e.g., shower chair with back, long-handled reacher, weighted utensils, power wheelchair, CPAP]
HCPCS code: [CODE]
Diagnosis: [ICD-10]
Functional assessment findings: [SPECIFIC — what the patient cannot do without this equipment, objective assessment data supporting need]
Why this specific equipment: [CLINICAL RATIONALE — why this item and not a less expensive alternative]
OT assessment performed: [DATE — face-to-face evaluation required for most DME]
How equipment addresses functional limitation: [DIRECT CONNECTION — e.g., "Shower chair will allow patient to complete bathing safely with supervision only, eliminating fall risk currently requiring 2-person assist"]
Supporting documentation attached: [EVALUATION REPORT / FUNCTIONAL ASSESSMENT / PRESCRIPTION]

Under 300 words.

Write an OT prior authorization denial appeal letter.

OT: [NAME, OTR/L]
Patient: [NAME, AGE, INSURER — CLAIM OR AUTH NUMBER]
Denial reason: [EXACT LANGUAGE FROM DENIAL LETTER]
Rebuttal to denial reason: [SPECIFIC CLINICAL COUNTER-ARGUMENT — address the exact denial reason with evidence]
Clinical evidence supporting medical necessity: [STANDARDIZED ASSESSMENT SCORES, FUNCTIONAL MEASUREMENTS, CLINICAL GUIDELINES CITED]
Clinical guidelines referenced: [AOTA GUIDELINES / CMS COVERAGE CRITERIA / PUBLISHED EVIDENCE BASE]
Patient-specific factors making this case different from "routine": [COMPLICATING FACTORS — comorbidities, safety risk, lack of informal caregiver support, complexity of presentation]
Request: [OVERTURN DENIAL AND AUTHORIZE REQUESTED SERVICES]
Contact for peer-to-peer: [NAME AND DIRECT LINE]

Under 300 words. Lead with your clinical counter-argument in the first sentence — do not restate the denial before making your case.

Write a letter of medical necessity for a home modification from an occupational therapist.

OT: [NAME, OTR/L, NPI]
Patient: [NAME, AGE, DIAGNOSIS]
Funder: [MEDICAID WAIVER / VA / INSURANCE — PROGRAM NAME]
Modification requested: [SPECIFIC — e.g., installation of roll-in shower, widening of doorways to 36 inches, installation of stair lift]
Estimated cost: [IF KNOWN]
Home assessment performed: [DATE]
Patient's functional status: [SPECIFIC DEFICITS — mobility, balance, transfer ability, relevant measurements]
Current safety risk: [SPECIFIC INCIDENT HISTORY OR RISK EVIDENCE — e.g., "patient has had 2 falls in the past 90 days during bathing transfers"]
Why modification is medically necessary: [DIRECT CLINICAL CONNECTION — without this modification, patient faces X risk or requires Y level of care that would not otherwise be necessary]
Alternative equipment considered and why insufficient: [WHY DME ALONE DOES NOT ADDRESS THE NEED]
Expected functional outcome: [HOW MODIFICATION WILL CHANGE PATIENT'S INDEPENDENCE AND SAFETY]

Under 350 words.

Write a letter clarifying occupational therapy's role and scope for an insurance reviewer or case manager.

OT: [NAME, OTR/L]
Patient: [NAME, AGE]
Insurer: [NAME — CASE MANAGER OR MEDICAL DIRECTOR IF KNOWN]
Context: [WHY THIS LETTER IS NEEDED — e.g., insurer questioning why OT and PT are both treating same patient / insurer conflating OT with PT / confusion about OT's role in cognitive rehab]
OT scope of practice clarification: [SPECIFIC — what OT addresses that PT does not; e.g., "Occupational therapy addresses functional performance in daily tasks including self-care, home management, and cognitive demands of daily living — distinct from PT's focus on mobility and musculoskeletal function"]
This patient's OT-specific goals: [SPECIFIC ADL/IADL/COGNITIVE/UE GOALS THAT ARE OT'S CLINICAL DOMAIN]
Why duplication of care does not apply: [SPECIFIC — how OT and PT treatment for this patient are clinically distinct]
Reference: [AOTA SCOPE OF PRACTICE DOCUMENT / CMS OT BENEFIT POLICY]

Under 300 words.

Write IEP annual goals for a school-based occupational therapy student.

Student: [AGE, GRADE, DIAGNOSIS]
Evaluation summary: [KEY ASSESSMENT FINDINGS — standardized scores, functional skill level in school context]
Areas of concern for IEP goals: [SELECT — fine motor / handwriting / self-care in school / sensory regulation / visual motor integration / assistive technology]

Write 3 IEP annual goals in the format: By [DATE], [STUDENT] will [OBSERVABLE BEHAVIOR] as measured by [MEASUREMENT METHOD] with [ACCURACY/FREQUENCY CRITERIA] across [SETTINGS/CONDITIONS].

Goal 1 — [SKILL AREA]: [COMPLETE GOAL TEXT]
Goal 2 — [SKILL AREA]: [COMPLETE GOAL TEXT]
Goal 3 — [SKILL AREA]: [COMPLETE GOAL TEXT]

Short-term objectives for each goal (2 per goal): [MEASURABLE STEPPING STONES TOWARD ANNUAL GOAL]
Recommended OT services: [FREQUENCY, SETTING — push-in / pull-out / consultation, group vs. individual]

Goals must be observable, measurable, functional, and educationally relevant — not impairment-based.

Write an occupational therapy patient education handout on joint protection and energy conservation.

Patient diagnosis: [E.G., Rheumatoid Arthritis / Osteoarthritis / Fibromyalgia / Lupus]
Key joints affected: [SPECIFIC JOINTS — e.g., wrists, MCP joints, hips, knees]
Joint protection principles to cover (select relevant):
- Avoid positions that stress small joints
- Distribute load to larger joints
- Avoid sustained grip
- Use assistive devices
- Modify activities to reduce joint stress

For each principle: [PLAIN LANGUAGE EXPLANATION + SPECIFIC EVERYDAY EXAMPLE relevant to this patient's condition]
Energy conservation strategies: [3–5 SPECIFIC — pacing, work simplification, rest breaks, activity scheduling]
Equipment recommendations: [ADAPTIVE KITCHEN TOOLS, JAR OPENERS, ERGONOMIC UTENSILS, LEVER-STYLE DOOR HANDLES — specific to affected joints]
What to avoid: [SPECIFIC ACTIVITIES AND POSITIONS THAT INCREASE JOINT DAMAGE RISK]
When to contact OT: [SPECIFIC TRIGGER SYMPTOMS]

Under 350 words. Plain language. Patients with chronic conditions manage better when they understand the "why" behind each recommendation.

Write a documentation audit preparation summary for an occupational therapy department or solo practitioner.

Setting: [OUTPATIENT / SNF / HOME HEALTH / SCHOOL]
Payer under review: [MEDICARE / MEDICAID / COMMERCIAL]
Audit type: [PRE-PAYMENT REVIEW / TARGETED PROBE AND EDUCATE / CERT / RAC]
Documentation elements to review for each chart: [GENERATE A CHECKLIST FOR — evaluation completeness, skilled care justification per note, G-code compliance, plan of care signatures, progress note frequency, functional measurement documentation, discharge note compliance]
Common audit findings in [SETTING]: [MOST FREQUENT DEFICIENCIES FOR THIS CARE SETTING]
Self-audit protocol: [STEP-BY-STEP CHART REVIEW PROCESS — what to check in each note]
Corrective action if deficiencies found: [HOW TO DOCUMENT ADDENDA WITHOUT ALTERING RECORDS]
Resources: [CMS OT COVERAGE DETERMINATION / MAC LOCAL COVERAGE ARTICLE RELEVANT TO SETTING]

Under 400 words. Audit preparedness is documentation quality — use this checklist before every authorization renewal.

Write an occupational therapy caregiver training documentation note.

Patient: [AGE, DIAGNOSIS]
Caregiver: [RELATIONSHIP — spouse, adult child, paid caregiver — do not use name in clinical note]
Training session date: [DATE]
Skills trained this session: [SPECIFIC — e.g., safe transfer technique from bed to wheelchair, donning lower body prosthesis, cueing strategies for patient with dementia during morning ADLs]
Caregiver's baseline skill level before training: [WHAT THEY WERE DOING BEFORE / NO PRIOR TRAINING]
Teaching methods used: [VERBAL INSTRUCTION / DEMONSTRATION / RETURN DEMONSTRATION / WRITTEN HANDOUT]
Caregiver performance at end of session: [SPECIFIC — e.g., "Caregiver demonstrated safe pivot transfer with verbal cues only, no physical prompting required by OT"]
Safety issues addressed: [SPECIFIC — body mechanics, patient positioning, fall risk management]
Items caregiver still needs practice on: [SPECIFIC]
Next training session plan: [TOPIC AND DATE]

Under 300 words. Caregiver training is a skilled OT service — document it as systematically as direct patient treatment.

Write a professional development case study summary for an occupational therapist's portfolio or CEU reflection.

Diagnosis or population: [SPECIFIC — e.g., pediatric sensory processing disorder / adult CVA with cognitive deficits / geriatric fall prevention in SNF]
Clinical challenge presented: [WHAT MADE THIS CASE COMPLEX OR INSTRUCTIVE]
OT evaluation approach: [ASSESSMENTS USED, OCCUPATIONAL PROFILE FINDINGS, CLINICAL REASONING AT EVALUATION]
Intervention approach: [TREATMENT FRAMEWORK — Model of Human Occupation / Biomechanical / Neurodevelopmental / Sensory Integration — and specific interventions used]
Outcomes achieved: [SPECIFIC — functional changes, assessment score changes, patient/family report]
Clinical decision-making highlights: [2–3 MOMENTS WHERE OT CLINICAL JUDGMENT SIGNIFICANTLY AFFECTED OUTCOMES]
What I would do differently: [HONEST REFLECTION — not self-criticism, but professional growth]
Evidence base used: [CLINICAL GUIDELINES, RESEARCH REFERENCED]
Takeaway for practice: [ONE SPECIFIC INSIGHT THAT CHANGED OR REFINED MY CLINICAL APPROACH]

Under 400 words. Case studies are most valuable when they capture the complexity of clinical reasoning — not just what happened.