OT documentation

Your reasoning. A clearer note.

Dictate or type freely, then shape a source-supported SOAP note.

CASE-
Anonymous case code

Fictional or properly de-identified cases only. A client code alone is not de-identification. This version is not approved for identifiable clinical information.

1Capture & reason
2Organize & review
3Copy or export

Session source

Your observations and clinical reasoning.

I am using a fictional case or information de-identified under my organization’s approved process.

English · on-device only

Stream-of-consciousness transcript

0 wordsNo draft history saved

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Keep the occupation in the note.

Connect what limits performance, your skilled intervention, and the occupation it supports. A smoother sentence is useful only when that connection is yours.

Your documentation draft

Review the source before accepting the wording.

Awaiting source

Occupational therapy note

CASE- · Occupational therapy review draft

Functional Problem Statement:

[Performance deficit + skilled intervention + occupation]

Subjective:

[Client or caregiver perspective]

Objective:

[Observed context + intervention + purpose + response]

Assessment:

[Your interpretation of function and progress]

Clinical Necessity:

[Your rationale for continued skilled services]

Plan:

[Your next session and longer-term plan]

AI rewrites supported content into full sentences. Compare its proposal with your source before accepting.

I checked the note against the source. The clinical reasoning is my own, all statements are supported, and any AI changes preserve the meaning.

Organize your source to start the review.