The note reads: "Worked on fine motor skills. Student did well." It is dated, signed, and entirely accurate. It also answers none of the questions a team will ask: which skill, how well, with what help, toward which goal?
School OT notes have a different job from clinic notes. They have to show how the therapy connects to the student's IEP and educational program, and they have to do it briefly. This guide pulls the content of a good school OT note from two professional sources and the IEP rule, and gives a sample.
What the Illinois practices say a record should hold
The Illinois recommended practices were written by the OT and PT Coordinator Consortium of Northern Illinois as an update of an earlier state board of education document. They say therapy practitioners must account for intervention time as stated in a student's IEP or Section 504 plan and document interventions and student progress. They say each district may decide the format, and that the format should reference guidelines from national organizations such as AOTA and APTA.
For each student, the practices say records should include the goals being supported, the intervention plan, progress notes and attendance data, progress monitoring data on goals, and other information as appropriate, such as positioning or sensory programs.
What a therapy log contains
The document describes a service contact or therapy log, used to document activities such as working directly with the student, adapting equipment or the environment, or meeting with the IEP team. It also covers training given to paraprofessionals, other staff, and parents. Its recommended content is short.
| Content | Notes |
|---|---|
| Date of the activity | Always |
| Duration, if direct contact | Minutes actually spent |
| Type of contact | Direct, consult, training, meeting, and so on |
| Brief description of the activity or goal area | One line |
| Attendance and participation | May be included |
| Activities, techniques, and modalities | May include type of cuing, manual input, and level of assistance |
| Equipment issued or made, with instructions | May be included |
| Training, education, or consultation given or received | May be included |
| The student's response, related to the IEP | May be included |
| Plan for next steps and any needed follow-up | May be included |
Say what help the student had
For OT, the most useful fact in a note is often how much help the student needed. "Did well" cannot be compared across days. "Wrote the first line with a verbal cue and the second line independently" can.
AOTA's decision guide advises documenting contextual features that may affect performance, such as distractions in the environment, the cues provided, and whether a different person helped. Use a fixed set of words for assistance, and use them the same way every time.
| Level | What it means in the note |
|---|---|
| Independent | No cue or help from an adult |
| Verbal cue | Adult says what to do or how |
| Gesture or model | Adult points or shows the movement |
| Hand-over-hand | Adult guides the student's hand |
| Adapted | Equipment or the task was changed, and the change is named |
Write which level, how many times, and for which part of the task.
How progress is measured
The Illinois practices say practitioners measure progress toward IEP goals using criteria set by the team, and that the criteria for mastery can be time, distance, repetitions, percentages, accuracy, completion of trials, or quantified assistance levels, as stated in the IEP. The measurement strategy is also stated in the IEP and may include work samples, observation, checklists, charting, daily logs, and formal tests. For goals about behavior, the document says a method to convert qualitative performance into quantitative data is needed, and it names goal attainment scaling as one such tool. See rating scales in session notes for how to build one.
AOTA's guide adds that a student's baseline should be collected, that the team should set a data collection schedule, and that trends should be shared with the IEP team. Baseline data for IEP goals goes through that step.
A sample entry
Notice the pieces: time, setting, goal, task, count and total, assistance, a plain note about the student's behavior, and a next step.
Equipment and training
The Illinois practices suggest recording equipment issued or made, with specific instructions for its use, and training or instruction given to staff and parents. If you give a student a slant board or a pencil grip, or show an aide how to set it up, write the date, what you gave or showed, and to whom.
If progress is slow
The same guidance says that practitioners who decide a student is not making adequate progress should communicate with other team members to decide whether an IEP meeting is needed to consider changes. Your notes are the evidence. Write the numbers, the dates, and the conditions, and share the pattern, not one day.
Photos, videos, and work samples
Work samples are a common kind of OT data. The Illinois document lists work samples, checklists, rubrics, and observation as acceptable, and notes that photos or videos are sometimes used, with parent consent strongly recommended as directed by the district. Check your district's policy, store samples only where it says, and keep other students out of any image. For the privacy side, see FERPA and session notes.
What a claim needs
The Illinois document says therapy practitioners often have to document services provided, dates of service, and the duration of each session, and that the district handles billing. Medicaid rules differ by state, so ask your billing office. For the general picture, read school Medicaid documentation basics.
OT note slips
- "Fine motor" with no skill named. Name the skill and the task.
- A score with no assistance level. The same count with and without cues is not the same result.
- Copying the goal into the note. The note should show what happened.
- Treating consult as a session. Log it separately, as in consult time versus direct service time.
For the general note structure, see SOAP notes for school SLPs, which works for OTs too. Terms are in the glossary.