Clinical reports legible in addition to elimination of handwriting illegibility redoc also facilitates the reduction or elimination of shorthand. The basic outline of a therapy note should follow the soap format subjective objective assessment and plan both occupational therapy and physical therapy soap notes should have the same basic format whether you are writing an evaluation a daily note a progress note or a discharge note. Patient information last name first name mi hicn visit information date of service visits from soc date of treatment plan recert. Explore felicia bernsteins board ot documentation followed by 237 people on pinterest see more ideas about occupational therapy therapy ideas and pediatric ot. Occupational therapy evaluation 97003 neuromuscular reeducation therapeutic procedure 1 areas 97112 12 1 self care home management training direct contact 97535 12 1
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