School-Based Occupational Therapy Progress Notes

If you’re looking for a school-based occupational therapy daily notes template, you’ve arrived in the right place.

In the article below we’ll discuss everything you need for school-based occupational therapy progress notes.

Just like being an occupational therapist in any other clinical setting, working as a school-based OT requires thorough documentation, including session notes and occupational therapy progress notes. 

Occupational therapy standards of practice dictate that school-based therapists keep notes on each session. They usually also require progress notes on a semester or trimester basis. 

Many school-based clinicians take notes in the form of occupational therapy SOAP notes.

However, with school-based OT caseloads that typically include 50 or more students per week, how do OTs capture and maintain notes on every student? And what type of notes should OTs use? 

Finally, and, perhaps, most importantly, when do you find the time to write all these school-based occupational therapy progress notes? 

There isn’t one right answer nor a one-size-fits-all approach that works for everyone. That said, here are some tips to get your documentation completed. 

A school-based occupational therapy daily notes template may help. 

Read on for helpful tips on school-based occupational therapy progress notes.

Occupational Therapy Progress Notes and Rationale for Documentation

Guidelines on documenting and recording notes are included in the occupational therapy standards of practice on the state and national level.

Keeping notes on your treatment sessions is essential.

School-based occupational therapy progress notes document why you are providing OT services to an individual student and to describe that student’s response to treatment. 

Other reasons for documentation include billing and insurance needs and session attendance validation. 

Your District May Have Requirements for School-Based Occupational Therapy Progress Notes

It’s important to be aware of your school district’s requirements in terms of daily notes. 

Some school districts require you to enter daily session notes into a computer program, while others ask that you take notes yourself and add them to the student’s file. Other districts may have no notes requirement at all. 

Whether or not your district has a requirement, it is best practice for OTs to write session notes. 

Always take session notes regardless of your school’s policy. 

Get Organized With a School-Based Occupational Therapy Daily Notes Template

It is important to get and stay organized with your session notes. 

Spend some time at the beginning of the year developing an organizational system for your notes. 

Templates for school-based occupational therapy progress notes can be incredibly helpful to use, so that all you have to do is add a student’s name. Organize your notes in a folder or binder or on your computer. 

Decide on a system or routine around when you will write your session notes. 

It’s important that your notes are done during your work hours. 

Writing your notes during working hours will help prevent burnout and reduce stress. It’s easy to fall into a routine of doing notes at home, after hours, or on the weekends, but it’s important to find a balance so this doesn’t happen. 

If you start off writing your notes during working hours it will be much easier to continue the habit. 

Make sure you advocate for yourself with your district and carve out time to write notes. 

You can explain to your district that notes are part of your standard of practice as a therapist. 

Many therapists use the last 3-5 minutes of their session to write notes, whereas others schedule time at the end of each day or week to write all their notes.

 Whatever you decide, make sure you have time built into your schedule from the beginning of the school year for the required documentation. 

Writing Occupational Therapy Progress Notes for Data Collection

Writing notes is a form of data collection. 

The point of writing notes is so that at the end of the semester/trimester you can go back through the data you have collected to determine progress on your student’s goals. 

This is how you can “prove” a goal was met or not met. Taking data is a requirement for FAPE (free and appropriate education) standards as a way to measure progress. 

When you write goals make sure to write them in such a way that they can be measured and data can be taken.

 Don’t overcomplicate your goals and ensure they are written with a functional outcome. This will make it easier when you are writing your session notes. 

Data collection also helps improve evidence of occupational therapy interventions. We frequently talk about “evidence-based practice.” 

This is where the evidence comes from. 

It can also help support your recommendations for increased or decreased service time or making adjustments such as moving a student to consultation or discharging them altogether. It’s much easier to make recommendations when you have the data to support them. 

Occupational Therapy SOAP Notes

Many school-based clinicians take notes in the form of SOAP notes. SOAP is an acronym that stands for subjective, objective, assessment, and plan. 

SOAP notes are an easy and effective way of capturing what happened in your session, while also allowing you to capture data. 

Although you may be involved with insurance companies less in the schools, you may occasionally need notes for insurance. For instance, many schools have requirements for Medicaid. 

SOAP notes are generally accepted by these institutions. 

If you are unfamiliar with or need tips on taking SOAP notes, here’s an article on SOAP note occupational therapy format that includes a free downloadable template. 

Other Important Information to Include in Your Notes 

In addition to documenting how the session went with the student, your school-based occupational therapy progress notes should also include other key pieces of information, such as:

1. Attendance

Keep track of when you saw your student, but also keep track of absences and why the student was absent (if you know).

2. Parent Contact

Make sure to document any and all contact with parents. This includes phone calls (including voice messages), texts, emails, or meetings. Even if a parent catches you in the hallway or at pick-up and asks you a question about your student, make sure to document the interaction.

3. Equipment

If your students have equipment including things like glasses, make sure to document if they had their equipment during your session. This can be things like reward systems, picture schedules, communication devices, or mobility devices.

4. Behavior or Injuries

If you have students with behaviors such as biting, hitting, kicking, or elopement make sure to document these (be sure to check school policy as they should have a documentation process for this). Kids also occasionally can get hurt during your session. If an injury occurs (no matter how minor), first take your student to the nurse to get checked out, then document it.

5. Medications

Some families disclose medications their children are taking. If this is the case, make sure to document things like medications, observed side effects, or medication changes. 

Final Keys to Remember

Some final details to remember when taking session notes:

• Notes can be shared. There are many people and entities notes can be shared with including the student’s team, the student’s parent, other service providers, and third-party billing institutions such as insurance companies.
  
• There are federal guidelines under IDEA (Individuals with Disabilities Act) about documentation. 
• Daily documentation is considered a “standard of practice” by AOTA (American Occupational Therapy Association).
• If a legal issue ever arises your notes can be helpful in showing the treatment you provided and the outcome. 
• Notes are helpful for other clinicians. If another OT takes over treating a student, your notes can be helpful to the therapist so they know what you were doing and where you left off. 
• Make sure you know your state guidelines for documentation. A lack of documentation can be considered professional misconduct. Not only could it jeopardize your professional license, but if you maintain personal liability insurance, you may only be covered if you have taken session notes. 

Once you establish a system and develop good note-taking habits, you’ll be on your way to capturing and keeping effective session notes. Use the SimplePractice occupational therapy notes software to carve out more time for your clients.

 

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