How to document a treatment session

A patient’s comprehensive treatment plan is developed based on the results and findings of the occupational therapist’s evaluation. Listed below, includes treatment ideas and examples of how-to document effectively in the acute care setting.

  • Therapeutic activities encompass

    • Activities of daily living (ADLs) (e.g., bathing, dressing, toileting, etc).

    • Vision

    • Neglect/Inattention

    • Cognition & Delirium

    • Sensory

    • Education

    Sitting Balance Activity

    • Patient engaged in functional reach activity while seated using cones requiring BUE and core isometric muscle contraction while reaching beyond BOS x12 inches with CGA (2x10 reps) in order to promote muscle strengthening, enhanced posture, and endurance for an activity to produce increased safety during bed mobility, functional transfers/ambulation, participation in ADLs/IADLs, and the prevention of falls.


  • AAROM Upper Extremity

    The patient engaged in AAROM of RUE working proximally to distally (shoulder flexion, shoulder abduction, adduction, external rotation, internal rotation, elbow flexion, elbow extension, wrist flexion/extension, fingers flexion/extension, abduction/adduction) within 2 planes (10 repetitions each movement) in order to decrease tone, increase strength and mobility, and re-establish correct movement patterns for ongoing independence with ADLs and IADLs.


  • The patient engaged in proprioceptive neuromuscular facilitation of the RUE to promote decreased spasticity and increase ROM performing 2 sets of 10 reps through D1 and D2 movement patterns. The patient was educated on observed compensatory movements demonstrated an understanding of education.