AI for occupational therapy documentation
Using AI for occupational therapy documentation can help streamline a significant component of managing an occupational therapy practice.
Summary
- AI for occupational therapy documentation significantly reduces admin time and burnout by generating high-quality OT notes in minutes instead of hours, helping therapists reclaim time and reduce after-hours work.
- OT-specific AI tools improve clarity and consistency by using standardized clinical language, reducing variability in terminology and making notes easier for payers, reviewers, and care teams to interpret.
- AI supports stronger clinical reasoning and goal writing by generating SMART, functional goals and structured SOAP notes aligned with real-world OT workflows. Download my free SMART goals worksheet.
- Therapists remain in full control — AI drafts notes, but clinicians review and finalize documentation to ensure accuracy, ethics, and professional judgment.
Streamline your practice with One EHR
- Scheduling
- Flexible notes
- Template library
- Billing & payments
- Insurance claims
- Client portal
- Telehealth
- E-fax
For occupational therapists practicing in any field, evaluations, sessions, progress notes, and discharge reports must reflect clinical reasoning, functional outcomes, and measurable goals.
Many therapists feel buried by the documentation, along with juggling heavy caseloads. Research published in the Journal of Medical Systems has shown that “The administrative burden associated with clinical documentation has been identified as a major contributor to health care professional (HCP) burnout.”
Artificial intelligence is an emerging area and a game-changer in healthcare documentation. Many therapists are beginning to benefit from AI tools that allow for efficient notes, improve clarity, and ensure clinical language. While occupational therapists are trained clinicians, the documentation tools they use aren’t necessarily built with clinical OT thought processes, which can present them with some challenges.
Common OT documentation challenges
1. Inconsistent terminology and language: Therapists use different words to describe similar client behaviors, such as difficulty with pencil use vs inconsistent grasp patterns impacting handwriting. This type of variability influences reviewers, payers, physicians, and auditors, and their ability to understand the impact of OT and the client’s progress.
2. Time: Many therapists finish their documentation after clinic hours. “The burden of clinical documentation is well-documented; evidence suggests that HCPs spend on average two hours outside the official working day on documentation tasks," according to the Journal of Medical Systems research. This increases burnout and risks of errors and omission of data.
Balancing details with efficient writing can be difficult for OTs as some EHR templates may force checkboxes, and then clinicians are left writing long paragraphs.
3. Goal Writing: Writing measurable and functional goals that meet payer requirements.
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Benefits of using AI for occupational therapy documentation
Choosing AI for occupational therapy documentation is changing workflows across healthcare, which is improving speed, accuracy, functional language, and clinician satisfaction.
Research from a JAMA Network open article suggests "that AI scribes are associated with reductions in the amount of time clinicians spend documenting and writing notes in the EHR.”
AI can draft notes within seconds based on what the therapist has inputted, session keywords, or even voice dictation. It now takes 2-5 minutes to write notes compared to 10-30 minutes without AI, which frees up time to focus on clients and less time on notes.
AI-trained OT specific language also helps generate SMART goals, which reduces variability between clinicians and increases consistency and clarity for reviewers.
A systematic review of over 120 studies indicated that “AI tools improve documentation by structuring data, annotating notes, evaluating quality, identifying trends, and detecting errors.”
AI models can also understand specific terms such as ADLs, sensory regulation, modulation, grading, and task analysis, which produce notes that feel like they are written by an OT.
Additionally, some AI tools can help with interventions, recommend re-assessment schedules, and support overall clinical decision-making. Overall, it can help ensure documentation is clear, concise, and meets payer and regulatory guidelines.
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How AI generates OT-specific SOAP and progress notes
AI for occupational therapy documentation works by combining natural language processing with clinical templates specifically designed for therapy workflows. The therapists provide information via voice dictation, bullet points, keywords, structured fields, or session video summary.
Then, the AI system organizes the information in a SOAP style or progress note format, incorporating clinical reasoning, occupational performance problems, client-related concerns, objective performance deficits, functional impact, and clinical and professional assessments with plans for next steps.
Once this is drafted, the AI system fine-tunes the language using functional terminology, ensures goals are SMART, and uses precise terms such as independent or moderate assistance, or consistent 4/5 trials.
Lastly, therapists review the AI-generated note, maintaining clinical control, while reducing the time and effort required for documentation.
Free Resources for Therapists
Click below and help yourself to peer-created resources:
Examples of OT SOAP notes and goals
Pediatrics
Subjective: Parents report client avoids handwriting tasks at home and gets frustrated with worksheets and coloring in lines.
Objectives: Client participated in a targeted fine motor activity for 15 minutes focusing on dynamic tripod grasp practice and bilateral hand use. Observed inconsistent pencil grip, and frequent shifts to immature grasp patterns and difficulty sustaining line-copying tasks.
Assessment: Client presents with impaired fine motor coordination, grip strength, inefficient grasp patterns, impacting handwriting readiness and participation in school-related tasks. Functional limitations include avoidance of writing tasks and limited legibility.
Plan: Continue skilled occupational therapy services for 1x/week for 12 weeks, focusing on fine motor strengthening and coordination activities, include grade handwriting tasks, and provide a home exercise program (HEP) for school and home carryover.
- Short-Term Goal: Client will demonstrate a functional tripod grasp during writing tasks in 4 out of 5 trials
- Long-Term Goal: Client will legibly copy a paragraph in fewer than 3 reversals in 4 out of 5 trials, within 2 months.
Adults
Subjective: Client reports left wrist pain (6/10) status/post (s/p) fall, with pain increasing while grasping and performing ADL tasks specifically self-care tasks.
Objective: Client requires moderate assistance to don socks and shoes due to increased wrist pain 6/10 during sustained grasping and pulling motions. Client demonstrated decreased grip endurance, avoidance of weight bearing through L wrist, and required frequent breaks during task completion.
Assessment: Wrist pain s/p fall is limited to the client's ability to perform lower-body dressing tasks independently. Pain is increased with sustained grasp, pulling, and weight-bearing through hand, resulting in decreased task performance, efficiency, and reliance on assistance. Skilled OT services are required to address pain management, task modification, and restoration of functional independence.
Plan: Continue skilled OT 1x/week for 6 weeks, focusing on joint protection education, adaptive dressing strategies, graded functional strengthening within pain tolerance, and activity pacing to reduce symptom exacerbation.
- Short-Term Goal: Client will independently don socks using a sock aid with pain at or below 3/10 using a sock aid, within 2 weeks.
- Long-Term Goal: Client will independently don and doff shoes and socks without adaptive equipment with a pain level of at or below 3/10 by discharge in 6 weeks.
Choosing an EHR with AI for occupational therapy documentation
Tools with AI for occupational therapy documentation vary significantly, and not all are designed to support the specialized language and workflow of occupational therapists.
When selecting an AI-powered EHR or note-writing tool, it's important to consider the features that align with your OT practice needs.
Streamline your practice with One EHR
- Scheduling
- Flexible notes
- Template library
- Billing & payments
- Insurance claims
- Client portal
- Telehealth
- E-fax
Resources for occupational therapists
TheraPlatform is an all-in-one EHR, practice management, and teletherapy software built with AI-powered notes for therapists to help them save time on admin tasks. It offers a 30-day risk-free trial with no credit card required and supports different industries and sizes of practices, including occupational therapists in group and solo practices.
More resources
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
- Insurance billing 101
- Practice management tools
Free video classes
- Free on-demand insurance billing for therapist course
- Free mini video lessons to enhance your private practice
- 9 Admin tasks to automate in your private practice
References
1. Bracken, A., Reilly, C., Feeley, A., Sheehan, E., Merghani, K., & Feeley, I. (2025). Artificial Intelligence (AI) – powered documentation systems in Healthcare: A systematic review. Journal of Medical Systems, 49(1). https://doi.org/10.1007/s10916-025-02157-4
2. Pearlman, K., Wan, W., Shah, S., & Laiteerapong, N. (2025). Use of an AI scribe and Electronic Health Record Efficiency. JAMA Network Open, 8(10). https://doi.org/10.1001/jamanetworkopen.2025.37000
3. Perkins, S. W., Muste, J. C., Alam, T., & Singh, R. P. (2024, June 1). Improving Clinical Documentation with Artificial Intelligence: A Systematic Review. Perspectives in health information management. https://pmc.ncbi.nlm.nih.gov/articles/PMC11605373
FAQs about AI for occupational therapy documentation
Will AI replace occupational therapists’ clinical judgment?
No. AI supports documentation efficiency, but therapists remain responsible for all clinical decisions, assessments, and final notes.
Is AI documentation compliant with payer and regulatory standards?
When built into a therapy-specific EHR, AI helps generate structured, compliant notes that meet clinical, payer, and audit requirements.
How does AI know OT-specific terminology and workflows?
OT-focused AI tools are trained on therapy language (e.g., ADLs, sensory regulation, grading, task analysis) and use clinical templates designed specifically for occupational therapy documentation.
