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Clinical Resources for Occupational Therapy - Buffalo Occupational Therapy
Defensive Documentation BOT Portal - Buffalo Occupational Therapy

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Therapeutic Activity SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Neuromuscular Re Education SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Therapeutic Exercises SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Self Care and Occupation Specific SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Miscellaneous Patient Education SOAP Note examples for occupational therapy BOT Portal - Buffalo Occupational Therapy
Psychosocial and Behavioral SOAP Notes 1 - Buffalo Occupational Therapy

Tip: Press either “Ctrl + F” or “Command+F” on your keyboard and search for a keyword related to your intervention. You will then be able to copy and paste the caption.

Documentation - Buffalo Occupational Therapy

Tips for Defensive Documentation

Use language from the OTPF-4

State rationale and skill as an analyst

State how it relates to your scope of practice

Be thorough and leave no room for interpretation 

Write so that nobody can  can question your value and competence

Write so nobody can question medical necessity and justification of services the first time

How to Build Treatment Documentation

with Language from the OT Domain

Building OT Treatment Rationale - Buffalo Occupational Therapy

Supporting Interventions

Billed under main intervention code based on primary purpose