Documentation & Insurance Reimbursement Quick Reference
Occupational Therapy Documentation Sample Templates
Goals Sample Templates:
In (time frame), (patient) will (increase/improve/participate) in (domain) by (LTG: skill / STG: activity) for (duration/quantity) with no more than (quantity) verbal cues (prompts/redirects) to support (assistance level) in (occupation) across all areas of their environment.
Template examples:
Within ___ weeks, ______________ will complete UB dressing with _________ assist and no more than _____ verbal cues in 4/5 opportunities for increased functional independence in daily life ADLs.
Within ___ weeks, ______________ will complete toileting with _________ assist and no more than _____ verbal cues for 4/5 opportunities increased functional independence in daily life ADLs.
Within ___ weeks, ______________ will complete self-feeding with _________ assist and no more than _____ verbal cues for ____ mins of meal for increased functional independence in daily life ADLs.
Within ___ weeks, ______________ will complete sit to stand transfer with _________ assist and no more than _____ verbal cues for increased functional independence in daily life ADLs.
Within ___ weeks, ______________ will complete grooming tasks (washing hair, oral hygiene, etc.) with _________ assist and no more than _____ prompts for increased functional independence in daily life ADLs.
Within ___ weeks, ______________ will tolerate gross motor activities for ___ mins of task without a meltdown/tantrum/behavioral outburst in 5 out of 7 days for increased participation in play.
Within ___ weeks, Using sensory strategies (e.g., breathing, heavy work, deep pressure, etc.), ___________________ will demonstrate appropriate sensory modulation skills in order to participate in __________ without aggression towards peers in 4 out of 5 activities as measured by staff report to improve social participation.
Within ___ weeks, _______________ will demonstrate increased ROM ability by successfully reaching for objects in 4 out of 5 attempts to improve participation in work-based activities and a safe return to work.
Subjective Sample Template:
Patient reports pain level __/10. Patient stated (Client concerns / Pain level / Direct quotes / Occupations compromised / Home setup / PLOF).
Objective Sample Template:
Patient demonstrated ___(performance quality)___ during ___(intervention/activity)___, with ___(no/min/mod/max - explain) vital/symptom response and ___(normal/immediate/delayed/persistent lack of)__ recovery. Presentation is consistent with ___ (pattern/condition)__. Rehabilitation response today was ___(poor/improved/good) because ___.
Clinical observations:
ROM:
MMT:
Sensation:
Strength (grip, pinch, etc.):
Mobility (balance / coordination / proprioception):
Function (performance):
Cognition:
ADL/IADL:
Transfer Status:
Vitals: (BP - _____ /_____ | HR - _____ | SpO2 - _____ | Glucose - _____ | Temp - ______ | RR - ______)
Assessment Sample Template:
Patient is a __[age]__ year-old ___[gender]___ who is s/p ___[injury/illness/disability/medical procedure]___ who is presenting with decreased participation in the following occupations (domains): ___[predict specific occupation deficit]___. Occupational performance is limited due to client’s ___[identify problem/deficit]____. Client is a good candidate for occupational therapy (or continued skilled occupational therapy services are indicated) to ___[improvement/intervention]____. (Add relevant info from clinical observation section)
Plan Sample Template:
Patient will be seen (#X) /week for minutes, for _______ weeks for ___(Intervention approach - remediation, compensation, prevention, etc.)___ and occupation-based intervention to regain independence (or substitute) with engagement in meaningful occupations; this includes the following:
Occupational Therapy Funding Justification Letter Template
[Date]
To: [Insurance/Agency Name]
From: [Therapist Name, Credentials]
Facility/Clinic: [Name / Address]
Contact: [Phone / Email]
RE: Medical Necessity
Dear Reviewer,
[Client Name], [DOB] presents with:
Primary diagnosis: [Diagnosis]
Relevant impairments: [e.g., decreased strength, cognitive deficits, impaired balance, sensory loss]
Impact on daily function: [e.g., difficulty with ADLs, IADLs, Social Participation, etc.]
The requested [device/service] is medically necessary to address these impairments and enable participation in essential daily activities. Without this intervention, the client is at risk for [functional decline, injury, hospitalization, caregiver burden, etc.].
Expected Functional Gains
With the recommended [device/service], the client is expected to achieve (SELECT what is appropriate, add or edit as warranted, delete what is not relevant):
Improved independence in: [ADLs/IADLs]
Enhanced participation or access: [describe]
Greater participation in home/community roles
Reduced caregiver assistance
These gains align with the client’s therapy goals and established OT treatment plan.
Safety Considerations
The client currently demonstrates safety risks including:
[Falls, unsafe transfers, wandering, difficulty accessing essential areas, etc.]
The requested [device/service] will reduce these risks by:
[Providing stability, improving access, supporting cognition, reducing physical strain, etc.]
This intervention is essential to maintain a safe living environment and prevent avoidable injury.
Cost/Value Justification
The requested [device/service] offers significant long‑term value by (SELECT what is appropriate, add or edit as warranted, delete what is not relevant):
· Reducing risk of costly medical events (e.g., falls, hospitalizations)
· Decreasing caregiver burden and need for paid support
· Supporting client independence, delaying or preventing higher‑level care placement
· Providing durable, long‑term use relative to cost
This investment supports both client outcomes and responsible resource utilization.
Conclusion
Based on clinical assessment and evidence‑based practice, [device/service] is essential for [Client Name]’s health, safety, and functional independence. I respectfully request approval for this medically necessary intervention.
Please contact me with any questions or if additional documentation is needed.
Sincerely,
[Therapist Name, Credentials] [License Number] [Clinic/Facility]