Occupational therapy session note: template and example

An occupational therapy session note is the short, dated written account of each session. It states what you offered the patient, what you observed and what changes for the next session.

What a session note is for in occupational therapy

The occupational therapy assessment sets the starting point. The session note tells the rest of the story, one session at a time. It has four practical uses.

• Keeping a trace of what was done. The French framework of activities and competences for occupational therapists (order of 5 July 2010) lists among the expected competences that of ensuring the traceability of the information gathered in the patient record. A session note is the simplest way to do this.
• Following the goals. Each note shows where the patient stands against the goals set at assessment. You can then adjust the intervention plan as sessions go on.
• Handing over. A colleague, the prescribing doctor or the team taking over should understand in one reading where the patient stands.
• Being accountable to the patient. The patient can ask to see the health information that concerns them. A clear, factual note reads well.

The French framework

Patient record and traceability

We found no text that requires occupational therapists to use a specific session note format. However, the 2001 ANAES recommendations (the HAS has since taken over its role) advise opening a record for each patient and keeping it up to date. They list the session follow-up sheet among the essential parts, with the date, the type of intervention, the means used and the observations.

Professional confidentiality

Article L1110-4 of the French Public Health Code protects the confidentiality of information about a person cared for by a health professional. Article 226-13 of the French Criminal Code punishes the disclosure of confidential information by a person who holds it through their profession. Your session notes are therefore confidential. They are shared only with professionals caring for the same patient, under the conditions set by law. Our guide to professional confidentiality for allied health practitioners covers these rules in more detail.

The patient's right of access

Article L1111-7 of the Public Health Code gives everyone access to all the information about their health held by health professionals and institutions. In private practice, the request goes directly to the professional. According to service-public.fr, the documents must be provided no later than 8 days after the request, and no earlier than after a 48-hour reflection period. The deadline becomes 2 months if the information is more than 5 years old.

In practice, write each note as a document the patient might read one day.

Medical prescription and funding

Article L4331-1 of the Public Health Code states that occupational therapists practise on medical prescription. Article R4331-1 lists the acts concerned, including assessments, therapeutic activities and fitting of equipment. A legal note published by the ANFE (the French occupational therapy association) states that acts outside this list, such as advice on home adaptation or assistive equipment, do not require a prescription. When there is a prescription, note its reference in the record.

On funding, the ANFE points out that the profession has no agreement with the French national health insurance and that its services are not reimbursed by it in private practice. Some financial aid exists depending on the patient's situation. It is covered in our article on occupational therapy reimbursement.

The session note template, section by section

Keep the same structure from one session to the next, to write faster and compare sessions. Each section takes one to three lines.

1. Identification

Patient name, session date, duration, place (practice, home, school, workplace) and format, individual or group. Give the session number in the series.

2. Session goal(s) linked to the plan

Restate the goal of the intervention plan worked on today, then the specific goal of the session. Phrase it as an everyday activity, for example "make a hot drink independently", rather than as an isolated function. The ANAES recommendations asked for goals that are realistic, understandable, concrete, precise and measurable.

3. Activities and real-life tasks

Describe what the patient did, in what setting and with what equipment.

4. Observations

This is the heart of the note. Describe what you saw.

• Occupational performance. The steps completed, their quality, safety, time taken and fatigue.
• Independence. The level of help needed, from no help to full help, including verbal prompts or partial physical help.
• Participation. Engagement in the activity, initiative taken, interest expressed by the patient.

5. Assistive equipment and adaptations tried

Note the equipment or adaptation tried, its settings and the result observed. Say whether it was a first trial, a loan or equipment the patient already owns.

6. Response of the patient and those around them

What the patient says about the session, what suits them or not, and what a carer who was present observed or asked. Use the patient's own words when they matter.

7. Progress against the goals

Place the session against the goal, which may be met, improving, stable or declining. Rely on something observable, such as the level of help, the number of steps completed or the duration.

8. Instructions and next steps

What the patient or those around them should do before the next session, what you plan to work on next, and any tasks to follow up (call to the doctor, quote, letter). End with the date of the next session.

Completed session note example

The example below concerns a fictional patient. It shows the expected level of detail, not a course of treatment.

• Identification. Mr Bernard. Session 6 of 12, at home, 45 minutes, individual. Follow-up after a stroke, GP prescription on file.
• Session goal. Plan: regain independence in preparing simple meals. Today's goal, make a hot drink independently in his kitchen, safely.
• Activities and real-life tasks. Making a cup of tea with the patient's own kettle and utensils. Two attempts. Before the second attempt, the utensils were grouped together on the left side of the worktop.
• Observations. First attempt completed with a verbal prompt for the order of steps. Second attempt completed without verbal prompts, with some hesitation when pouring the water. No unsafe situation observed. Patient reported fatigue at the end of the session.
• Assistive equipment and adaptations tried. Non-slip mat under the cup, first trial. The cup no longer slides while pouring. Utensils grouped on the left, to be kept.
• Response of the patient and those around them. Mr Bernard says he is "pleased to have done it on his own". His wife, who was present, asks when he will be able to do it without her.
• Progress. Goal improving. In session 4, verbal prompts at every step. Today, no verbal prompts on the second attempt.
• Instructions and next steps. Keep the utensils grouped on the left. Make tea each morning with his wife present. Next session on Tuesday, same activity, then preparing a cold snack.

For the initial assessment that sets these goals, see our occupational therapy assessment report template.

Common mistakes

• Writing the note several days later. Useful details fade quickly. A short note written right after the session is better than a long one pieced together later.
• Describing the activity without the observation. "Kitchen work" says nothing about progress. Note what the patient managed, and with what help.
• Losing the link with the goals. Without a progress section, each note stands alone and the final report becomes an exercise in memory.
• Judging rather than describing. "Patient poorly motivated" reads badly and does not help follow-up. Write instead "stopped the activity after ten minutes, says he is tired".

Save time with Delta

Delta is the clinical assistant for mental health and allied health professionals. You have two ways to take your notes. During the session, Delta transcribes what is said. After the session, you dictate your observations. You can also add written notes.

Delta then generates the session report, with a short summary, a detailed summary and topics for the next session. It takes your profession into account. It also updates the patient record, with a summary of the follow-up and the goals being tracked. You find the whole follow-up and its progress in one place. Delta also drafts letters, certificates and assessments, adapted to occupational therapy.

Data is hosted in France by an HDS-certified host, and AI processing takes place in France. The patient's name and identifying information are pseudonymised before the AI step. No audio file is kept, data is never used to train a model, and it is encrypted in transit and at rest.

Delta does not handle billing or scheduling, and does not include standardised tests. It works alongside your practice software. It runs in the browser, with a Mac and Windows app recommended during sessions. The trial lasts 14 days, with no card required. The Pro plan then costs €29 per month including VAT on an annual plan, or €35 per month including VAT on a monthly plan. To find out more, see Delta for occupational therapists.

Further reading

• Occupational therapy assessment: report template and outline to download
• SOAP vs DAP vs BIRP notes: the same session written in each format
• Home adaptation recommendations: the occupational therapist’s approach
• Occupational therapy reimbursement: coverage and financial aid
• Clinical document templates by profession

Frequently asked questions

Sources

• ANAES (HAS), Le dossier du patient en ergothérapie (patient records in occupational therapy), recommendations, May 2001
• Order of 5 July 2010 on the French State diploma in occupational therapy, framework of activities and competences (ANFE copy)
• Service-public.fr, Accès au dossier médical (access to medical records)
• AP-HP, Legal Affairs Department, Le secret médical (medical confidentiality)
• ANFE, ANGAK, Must occupational therapists always practise on medical prescription? (in French)