OT Documentation Cheat Sheet: A Practical Guide for Everyday Charting

Documentation is a core clinical skill in occupational therapy (OT)—but it’s also one of the most time-consuming parts of the job. Between packed schedules, complex patient needs, and payer expectations, many OTs spend more time thinking about how to document than focusing on care itself. That’s where an OT documentation cheat sheet can help. 

In this article, we’ll introduce a free OT documentation cheat sheet PDF and walk you through how you can use it in practice and why it can support clearer, more consistent charting across care settings.

What is an OT documentation cheat sheet?

An OT documentation cheat sheet is a concise, quick-reference guide that brings together commonly used documentation elements in one place. It’s not meant to replace clinical reasoning or standardized documentation systems. Instead, it serves as a reminder of key components that often need to be captured—especially on busy days, or at the end of a long treatment block.

Used intentionally, a cheat sheet can help you:

• Stay consistent in how you describe patient performance

• Reduce second-guessing during clinical documentation

• Keep essential elements top of mind when time is limited

Most OT documentation cheat sheets include reminders for documenting:

• Functional performance and activities of daily living

• Levels of assistance and cueing

• Key objective findings 

• Goal alignment and indicators of progress

• Skilled need and clinical rationale

To make these elements easier to reference during daily documentation, we’ve created a free Occupational Therapy Documentation Cheat Sheet PDF designed for use across care settings.

Why clear documentation matters in occupational therapy

OT documentation serves several purposes at once. It communicates patient status and progress to the care team, supports continuity of care across settings, and helps demonstrate the skilled value of occupational therapy services.

Clear, consistent documentation can help you:

• Improve interdisciplinary communication

• Support clinical decision-making

• Reduce ambiguity during handoffs or transitions of care

• Align treatment with goals and outcomes

• Meet payer and organizational expectations

When documentation is rushed or inconsistent, even well-delivered care can be challenging to interpret or support later. While a documentation cheat sheet won’t fix every documentation challenge, it can help reinforce consistency, reduce mental load, and support clearer charting during busy clinical days.

Core elements of effective OT documentation

Documentation requirements vary by setting, but strong OT notes often share a few foundational elements. A cheat sheet helps keep these elements visible and consistent.

Functional performance

OT documentation should clearly describe how a patient performs meaningful tasks, such as:

• Activities of daily living (ADLs)

• Instrumental ADLs

• Mobility or transfers

• Task initiation, sequencing, and completion

Anchoring documentation in function helps clarify relevance and demonstrate skilled intervention.

Objective findings and measures

Including objective data supports clinical clarity and progress tracking. This may include:

• Range of motion or strength observations

• Standardized outcome measures

• Task-specific performance metrics

• Cognitive or perceptual observations tied to function

Consistency in how findings are documented makes it easier to assess change over time.

Safety awareness and precautions

Safety is a core component of OT assessment and should be consistently reflected in documentation. Notes should clearly indicate whether patients are following relevant precautions and their level of safety awareness during functional tasks.

This may include:

• Adherence to precautions (e.g., weight-bearing, cardiac, post-surgical)

• Safety awareness during mobility or ADLs

• Cognitive or behavioral factors affecting safety (e.g., impulsivity, reduced insight)

Documenting safety status helps support clinical reasoning, risk management, and care continuity across providers.

Assistance levels and cueing

Using standardized assistance levels and clearly describing the type of cueing provided helps communicate patient independence, safety needs, and clinical decision-making. Clear language also reduces interpretation gaps across providers and care settings.

Patient education, engagement, and response

Occupational therapy is inherently collaborative, yet education and patient response are often underrepresented in documentation. Clear notes should reflect not only what the therapist provided, but how the patient or caregiver engaged with it.

This may include documenting:

• Patient or caregiver education (e.g., use of adaptive equipment, safety strategies, energy conservation)

• Training provided to family members or caregivers

• The patient’s demonstrated understanding, carryover, or need for reinforcement

Capturing patient response strengthens the clinical narrative and clarifies the effectiveness of skilled intervention.

Documentation example: “Patient demonstrated 100 percent carryover of hip precautions during lower body dressing following verbal instruction and visual demonstration.”

Clinical reasoning and skilled need

Effective documentation reflects why the intervention required skilled OT services. This includes linking impairments to functional limitations and briefly explaining clinical reasoning in plain, professional language.

Time-bound goals and plan of care adherence

Effective OT documentation is more than a snapshot of a single visit—it should tell a clear story of progress over time. Notes should consistently reference established short-term goals (STGs) and long-term goals (LTGs) to show whether the patient is progressing as expected.

Strong documentation also reflects plan of care adherence, answering questions such as:

• Is the patient progressing toward goals?

• Are interventions still appropriate?

• If progress has slowed or plateaued, why?

Briefly documenting contributing factors—such as increased pain, post-surgical precautions, medical changes, or reduced participation—helps contextualize outcomes and supports clinical decision-making.

Documentation example: “Patient demonstrates slowed progress toward STG due to increased shoulder pain following recent surgical precautions.”

Common OT documentation challenges

Even experienced clinicians encounter documentation friction. Common challenges include:

• Inconsistent language between clinicians or visits

• Overdocumentation that increases fatigue

• Underdocumentation that misses skilled rationale

• Mental overload at the end of a long treatment day

For example, after a full day of back-to-back treatments, it’s easy to document task completion without fully capturing the level of assistance, cueing, or clinical reasoning involved. Over time, those small omissions can make it harder for others to understand patient progress—or for you to quickly recall it later.

A documentation cheat sheet doesn’t eliminate these challenges. Still, it can help standardize key elements and reduce the cognitive effort required to recall what needs to be included in each note.

How to use the OT documentation cheat sheet PDF in practice

The OT Documentation Cheat Sheet PDF is designed to be flexible and easy to integrate into existing workflows, regardless of care setting or documentation system.

Clinicians commonly use it:

• During daily note writing, as a quick reference

• When documenting evaluations versus progress notes

• As a refresher, when switching care settings

• To support onboarding, precepting, or student supervision

Because the cheat sheet is EMR-agnostic, it works alongside existing documentation systems rather than adding another tool to manage.

Documentation pitfalls to avoid

The red flag list: phrases that weaken documentation

Some commonly used phrases may sound complete but fail to communicate skilled value or clinical reasoning. A documentation cheat sheet can help flag vague language and prompt clearer alternatives.

Examples of phrases to avoid or clarify include:

• “Patient tolerated treatment well”

• “Continue same plan”

• “No change noted”

Instead, aim to briefly explain why the intervention was effective or what clinical decision was made based on patient performance.

Strengthening the ‘Assessment’ section of SOAP notes

Within the commonly used SOAP note format (Subjective, Objective, Assessment, Plan), many occupational therapists find the Assessment section the most challenging to write well. This portion of the note should synthesize the Subjective and Objective findings into a concise clinical interpretation—rather than restating what already occurred.

A strong Assessment often includes:

• Interpretation of performance trends over time

• Progress toward established short- and long-term goals

• Clinical rationale for continuing, modifying, or progressing the plan of care

Instead of repeating objective data, the Assessment should explain what those findings mean for the patient’s functional performance and ongoing therapy needs.

Supporting your practice beyond documentation

Clear documentation is one part of effective occupational therapy practice. Other strategies can also support confident, consistent charting over time—especially as clinical demands change.

Continuing education to strengthen clinical reasoning

Continued education helps clinicians more clearly connect impairments, function, and intervention, making skilled needs easier to articulate in documentation.

Staying current with evidence-based practice guidelines

Familiarity with current recommendations supports clearer goal writing, intervention selection, and clinical rationale.

Using standardized outcome measures consistently

Routine use of the same tools supports clearer progress tracking and more efficient documentation over time.

Learning from real-world case examples

Reviewing how other clinicians document similar patient presentations can help refine language, structure, and clinical focus.

Medbridge Educate brings these elements together through an integrated education and training platform designed to support occupational therapists across care settings. From accredited continuing education to practical clinical resources, Medbridge supports ongoing learning that aligns with everyday practice—not just documentation requirements.

Documentation as clinical communication

At its core, documentation is a form of clinical communication. When notes clearly reflect patient performance, clinical reasoning, and progress, they support continuity of care across settings.

The OT Documentation Cheat Sheet PDF won’t replace professional judgment, but it can help make documentation more manageable. Used alongside consistent practices and ongoing learning, it supports clearer charting and more effective communication across the care team.